Cardiovascular Mortality in Obstructive Sleep Apnea in the Elderly: Role of Long-Term Continuous Positive Airway Pressure Treatment

The PAP-RES algorithm: Defining who, why and how to use positive airway pressure therapy for OSA

Obstructive sleep apnea (OSA) is a common condition that is increasing in prevalence worldwide. Untreated OSA has a negative impact on health-related quality of life and is an independent risk factor for cardiovascular diseases. Despite available data suggesting that cardiovascular risk might differ according to clinical phenotypes and comorbidities, current approaches to OSA treatment usually take a "one size fits all" approach. Identification of cardiovascular vulnerability biomarkers and clinical phenotypes associated with response to positive airway pressure (PAP) therapy could help to redefine the standard treatment paradigm. The new PAP-RES (PAP-RESponsive) algorithm is based on the identification of OSA phenotypes that are likely to impact therapeutic goals and modalities. The paradigm shift is to propose a simplified approach that defines therapeutic goals based on OSA phenotype: from a predominantly "symptomatic phenotype" (individuals with high symptom burden that negatively impacts on daily life and/or accident risk or clinically significant insomnia) to a "vulnerable cardiovascular phenotype" (individuals with comorbidities [serious cardiovascular or respiratory disease or obesity] that have a negative impact on cardiovascular prognosis or a biomarker of hypoxic burden and/or autonomic nervous system dysfunction). Each phenotype requires a different PAP therapy care pathway based on differing health issues and treatment objectives.

Sleep status of older adults with sleep apnoea syndrome may vary by body mass index

Obesity and ageing are the most important risk factors for sleep apnoea syndrome (SAS); however, the role of body mass index (BMI) on sleep status in healthy older adults is unclear. To explore sleep parameters according to BMI among active older adults, we cross-sectionally examined the relationship between sleep-related parameters and BMI in 32 Japanese adults aged from 83 to 95 years without long-term care who were unaware of having SAS. Correlation and linear regression analyses were performed. Moderate or severe SAS prevalence was high in both those with low (68.8%) and high (68.8%) BMI. A higher increase in apnoea-hypopnoea index (AHI) was negatively correlated with sleep depth in the high-BMI group. In the low-BMI group, the number of awakenings and age were positively correlated with AHI. Older adults may have SAS regardless of their BMI, and the sleep status of patients with SAS may vary by BMI.

Positive airway pressure therapy adherence and outcomes in obstructive sleep apnea: An exploratory longitudinal retrospective randomized chart review

Background

Positive airway pressure (PAP) therapy is prescribed to patients with obstructive sleep apnea (OSA). A commonly used definition for PAP therapy adherence is based upon the minimum requirements to receive Medicare coverage in the US, defined as PAP usage of four or more hours per night on 70 percent of nights for at least 30 consecutive days. However, little evidence exists to support this definition for PAP therapy adherence. Therefore, the present study sought to determine the efficacy of the present definition of PAP therapy adherence on longitudinal outcomes in patients with OSA, using objectively measured PAP device usage time.

Methods

An exploratory longitudinal, retrospective, randomized chart review was done to assess clinical outcomes between patients with OSA who were defined as PAP therapy adherent (n=50) and non-adherent (n=50) during an eight-year observation period.

Results

No significant differences were shown between groups for mortality, hospitalizations, or development of co-morbidities during the observation period. However, logistic regression showed significantly higher odds of adherence in male patients compared to female patients (OR=8.519; 95%CI=1.301-55.756; p=0.025) and significantly lower odds of adherence in patients with higher normal (OR=0.039; 95%CI=0.005-0.392; p=0.003), mild excessive (OR=0.039; 95%CI=0.003-0.517; p=0.014), and severe excessive (OR=0.088; 95%CI=0.012-0.635; p=0.016) daytime sleepiness compared to patients with lower normal daytime sleepiness. An increasing number of hospitalizations also corresponded with a significant decrease in odds of being adherent (OR=0.741; 95%CI=0.551-0.995; p=0.046).

Conclusion

The present study supports a steadily growing body of literature calling for more consideration and evidence to support a definition of PAP therapy adherence that is clinically meaningful.

CPAP adherence after ambulatory and in-hospital management in patients aged 65 years and older

OBJECTIVES

The aims of this study are to evaluate the early adherence to CPAP treatment in patients aged 65 years and older and to compare ambulatory (ACPAP) and in-hospital (HCPAP) management in starting CPAP treatment.

METHODS

Adherence to CPAP therapy at 3 months was retrospectively studied in patients on whom CPAP therapy was initiated between 1 January 2020 and 31 December 2021. Patients in the ACPAP group were selected based on the current Belgian reimbursement criteria (OAHI ≥30/h and few comorbidities).

RESULTS

146 patients were studied (median OAHI 43.35/h [32.02; 57.40]; median age 69 [67.0; 73.0]): 116 (79.5%) patients in the HCPAP and 30 (20.5%) in the ACPAP group. Based on an adherence threshold of average CPAP use of ≥ 4 hours per day, 120 (82%) patients were adherent to the treatment; 94 (81%) patients in the HCPAP and 26 (86.7%) in the ACPAP group. The median CPAP use for the total population was 6.4 h/day [4.89; 7.34], reaching 6.3 h/d [4.79; 7.15] for the HCPAP group and 6.8 h/d [6.21; 8.06] for the ACPAP group (p = 0.019). Insomnia was a significant risk factor for non-adherence (OR 5.16 [1.64; 16.08], p = 0.0043) but the ACPAP method was not (OR 0.66 [0.18; 1.91], p = 0.4748).

CONCLUSION

Early CPAP adherence in patients ≥ 65 years old was good in terms of average use per day and proportion of adherent patients. ACPAP method was not a risk factor for lower CPAP adherence in patients presenting severe OSAS (OAHI ≥30/h) and few comorbidities.

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.

Pharmacotherapy for obstructive sleep apnea: targeting specific pathophysiological traits

INTRODUCTION

The pathophysiology of obstructive sleep apnea (OSA) is multi-factorial and complex. Varying OSA's pathophysiological traits have been identified, including pharyngeal collapsibility, upper airway muscle reactivity, arousal threshold, and regulation of the ventilatory drive. Being CPAP of difficult tolerance and other interventions reserved to specific subpopulations new pharmacological treatments for OSA might be resolutive.

AREAS COVERED

Several existing and newly developed pharmacological drugs can impact one or more endotypes and could therefore be proposed as treatment options for sleep disordered breathing. With this review we will explore different pathophysiological traits as new targets for OSA therapy. This review will summarize the most promising pharmacological treatment for OSA accordingly with their mechanisms of action on upper airway collapsibility, muscle responsiveness, arousal threshold, and loop gain.

EXPERT OPINION

Only understanding the pathophysiological traits causing OSA in each patient and placing the disease in the framework of patient comorbidities, we will be able to evolve interventions toward OSA. The development of new drug's combinations will permit different approaches and different choices beside conventional treatments. In the next future, we hope that sleep specialists will select the treatment for a specific patient on the base of its pathophysiology, defining a precision medicine for OSA.

Super-multifactorial survey YHAB revealed high prevalence of sleep apnoea syndrome in unaware older adults and potential combinatorial factors for its initial screening

Study Objectives: Aging is a risk factor for sleep apnoea syndrome (SAS), which is associated with lower quality of life and sudden mortality. However, SAS is often overlooked in older adults without suspicions. Therefore, this study aimed to evaluate SAS incidence and 48 other general factors in older adults. Methods: This cross-sectional study included all non-caregiver-certified, healthy individuals (N = 32) who survived during the long-term cohort study and agreed to participate in apnoea-hypopnoea index (AHI) measurement (aged 83-95 years). AHI and 48 other general factors were evaluated, and simple linear regression analysis was used to identify potential AHI-related factors. Stepwise evaluation was further performed using multiple linear regression analyses. Results: Although no individuals were previously diagnosed with SAS, 30 (93.75%) participants had some degree of SAS (AHI > 5/h), and 22 (68.75%) had severe or moderate SAS (AHI > 15/h). Compared with typical single risk factors represented by body mass index, combining daily steps and other factors improved the fit to the multiple linear regression. Combining daily steps and body mass index improved the fit for males and combining daily steps and red blood cell count improved the fit for females. Conclusion: SAS was highly prevalent in unaware healthy Japanese older adults; combinations of daily steps and body mass index, and daily steps and red blood cell count may predict AHI in such individuals without the need for a specific AHI test.

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.

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.

High adherence to continuous positive airway pressure (CPAP) in patients with obstructive sleep apnea (OSA) in Belgium: a narrative review

OBJECTIVES

Continuous positive airway pressure (CPAP) is the 'gold standard' treatment for moderate-to-severe obstructive sleep apnea (OSA); adherence is an important issue. The aim of this paper is to review Belgian data on CPAP users and their adherence over a period of 11 years.

METHODS

Data delivered annually by the CPAP centers to the Belgian National Institute for Health Insurance (RIZIV/INAMI) were studied. Comments on these results were embedded in a narrative review.

RESULTS

On 1 January 2008 27.266 Belgian patients were treated with CPAP, at the end of 2018 this number increased to 121.605. In 2018, the short-term adherence (≤3 months) to CPAP was at least twice as high compared to the United States: the CPAP termination rate in Belgium (mainly due to stop of reimbursement because adherence <4 h/night) was estimated to be 12.4%, considerably lower than the 31.1% of patients on CPAP in the United States using the device <4 h.

CONCLUSION

We speculate that this good adherence might be attributed to a stringent Belgian diagnostic and treatment convention model. This model uses 'gold standard' techniques (including in-hospital polysomnography), imposes a minimum capacity of medical doctors and paramedical collaborators, a strict follow-up of the patients, multidisciplinary care and proof of competency. Taking into account the increasing number of patients, a change in the Belgian care strategy is under consideration focusing on more out-of-centre patient's management; we propose a step-by step approach with careful monitoring of the impact of changing policy on adherence.

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

Endothelial Dysfunction and Cardiovascular Risk in Obstructive Sleep Apnea: A Review Article

Obstructive sleep apnea (OSA) is a respiratory condition during sleep caused by repeated pauses in breathing due to upper airway obstruction. It is estimated that OSA affects 30% of the population, but only 10% are well diagnosed due to the absence of a well-defined symptomatology and poor screening tools for early diagnosis. OSA is associated to an endothelial dysfunction inducing several biological responses such as hypoxia, hypercapnia and oxidative stress, among others. OSA also triggers respiratory, nervous, metabolic, humoral and immunity system activations that increase the possibility of suffering a cardiovascular (CV) disease. In this review, we expose different studies that show the relationship between OSA and endothelial dysfunction and its association with CV pathologies like hypertension, and we define the most well-known treatments and their limitations. Additionally, we describe the potential future directions in OSA research, and we report clinical features such as endothelial progenitor cell alterations that could act as biomarkers for the development of new diagnostic tools and target therapies.

Moderate obstructive sleep apnea and cardiovascular outcomes in older adults: a propensity score-matched multicenter study (CPAGE-MODE study)

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) has been associated with cardiovascular events (CVEs), although recent randomized controlled trials have not demonstrated that long-term continuous positive airway pressure (CPAP) prevents CVEs. Our objective was to determine the effect of CPAP on older adults with moderate OSA regarding CVE reduction.

METHODS

An observational and multicenter study of a cohort of older adults (> 70 years of age) diagnosed with moderate OSA (apnea-hypopnea index 15.0-29.9 events/h) was conducted. Two groups were formed: (1) CPAP treatment and (2) standard of care. The primary endpoint was CVE occurrence after OSA diagnosis. Association with CPAP treatment was assessed by propensity score matching and inverse weighting probability. Secondary endpoints were incidence of CVE separately and time to first CVE.

RESULTS

A total of 614 patients were included. After matching, 236 older adults (111 men, mean age 75.9 ± 4.7 years) with a follow-up of 47 months (interquartile range: 29.6-64.0 months) were considered for primary and secondary endpoint evaluations. Forty-one patients presented at least 1 CVE (17.4%): 20 were in the standard-of-care group (16.9%) and 21 were in the CPAP group (17.8%), with a relative risk of 1.05 (95% confidence interval [CI], 0.60-1.83; P = .43) for CPAP treatment. Inverse probability weighting of the initial 614 patients determined an adjusted relative risk of 1.24 (95% CI, 0.79-1.96; P = .35) for CPAP treatment. No statistical differences were found in secondary endpoint analyses.

CONCLUSIONS

CPAP should not be prescribed to reduce CVE probability in older adults with moderate OSA.

CITATION

López-Padilla D, Terán-Tinedo J, Cerezo-Lajas A, et al. Moderate obstructive sleep apnea and cardiovascular outcomes in older adults: a propensity score-matched multicenter study (CPAGE-MODE study). J Clin Sleep Med. 2022;18(2):553-561.

Obstructive Sleep apnea and cardiovascular events in Elderly Patients

INTRODUCTION

In recent decades, life expectancy has increased considerably. The cardiovascular effects of Obstructive Sleep Apnea (OSA) in the elderly lead to patient disability and high resource consumption. Intermittent nocturnal hypoxia leads to hemodynamic stress and adrenergic activation, which promotes cardiovascular disease. However, chronic intermittent hypoxia may protect elderly patients from cardiovascular events (CVE) due to biological adaptation.

AREAS COVERED

OSA patients are at increased risk of cardiovascular events. The severity of OSA increases cardiovascular risk, and this association also exists in the elderly. This article reviews the association between OSA, CPAP treatment, and CVE, particularly stroke and coronary heart disease (CHD), in the elderly. MEDLINE and the Cochrane Collaboration databases were searched from inception to July 2021.

EXPERT COMMENTARY

Although a positive association between OSA and the incidence of cardiovascular disease in the elderly has been established, the role of sleep apnea in certain cardiovascular events remains controversial. Most authors agree that untreated OSA is a risk factor for stroke or worse stroke prognosis. However, the association between OSA and CHD is usually less pronounced than between OSA and stroke, especially in the elderly.

Sleep and Stroke: Opening Our Eyes to Current Knowledge of a Key Relationship

PURPOSE OF REVIEW

To elucidate the interconnection between sleep and stroke.

RECENT FINDINGS

Growing data support a bidirectional relationship between stroke and sleep. In particular, there is strong evidence that sleep-disordered breathing plays a pivotal role as risk factor and concur to worsening functional outcome. Conversely, for others sleep disorders (e.g., insomnia, restless legs syndrome, periodic limb movements of sleep, REM sleep behavior disorder), the evidence is weak. Moreover, sleep disturbances are highly prevalent also in chronic stroke and concur to worsening quality of life of patients. Promising novel technologies will probably allow, in a near future, to guarantee a screening of commonest sleep disturbances in a larger proportion of patients with stroke. Sleep assessment and management should enter in the routinary evaluation of stroke patients, of both acute and chronic phase. Future research should focus on the efficacy of specific sleep intervention as a therapeutic option for stroke patients.

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.

Impact of Desaturation Patterns versus Apnea-Hypopnea Index in the Development of Cardiovascular Comorbidities in Obstructive Sleep Apnea Patients

Various phenotypes of obstructive sleep apnea (OSA) have been recently described and are poorly assessed by the commonly used polysomnographic indices, such as the apnea-hypopnea index and oxygen desaturation index. Nocturnal hypoxemia is the hallmark of OSA and new quantitative markers, as hypoxic burden or desaturation severity, have been shown to be associated with cardiovascular (CV) mortality. The purpose of this overview is to review the endophenotypical and clinical characteristics of OSA, the current metrics, and to analyze different measurements of hypoxemia in OSA to predict the cardiovascular impact (eg hypoxic burden). Potential interest of multidimensional models to classify OSA, such as BAVENO classification, is also discussed, with the goal of focusing on specific endophenotypes that are likely to develop CV comorbidities, in order to guide clinicians to more aggressive management of OSA in these individuals.

Effect of continuous positive airway pressure in very elderly with moderate-to-severe obstructive sleep apnea pooled results from two multicenter randomized controlled trials

STUDY OBJECTIVE

There is very limited information about the effect of continuous positive airway pressure (CPAP) in the very elderly. Here we aimed to analysed the effect of CPAP on a clinical cohort of patients with obstructive sleep apnea (OSA) ≥80 years old.

METHODS

Post-hoc pooled analysis of two open-label, multicenter clinical trials aimed to determine the effect of CPAP in a consecutive clinical cohort of elderly (≥70 years old) with moderate-to-severe OSA (apnea-hipopnea index ≥15 events/hour) randomized to receive CPAP or no CPAP for three months. Those consecutive patients ≥80 years old were included in the study. The primary endpoint was the change in Epworth Sleepiness scale (ESS). Secondary outcomes included sleep-related symptoms, quality of life, neurocognitive and mood status as well as office blood pressure measurements.

RESULTS

From the initial 369 randomized individuals with ≥70 years, 97 (26.3%) with ≥80 years old were included (47 in the CPAP group and 50 in the no-CPAP group). The mean (SD) age was 81.5 (2.4) years. Average use of CPAP was 4.3 (2.6) hours/night (53% with good adherence) Patients in the CPAP group significantly improved snoring and witnessed apneas as well as AHI (from 41.9 to 4.9 events/hour). However no clinical improvements were seen in ESS (-1.2 points, 95%CI, 0.2 to -2.6), any domain of QSQ, any neurocognitive test, OSA-related symptoms, depression/anxiety or blood pressure levels.

CONCLUSIONS

The present study does not support the use of CPAP in very elderly patients with moderate-to-severe OSA.

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.

Upper airway muscles: influence on obstructive sleep apnoea pathophysiology and pharmacological and technical treatment options

PURPOSE OF REVIEW

Obstructive sleep apnoea (OSA) is highly prevalent with numerous deleterious effects on neurocognitive and cardiovascular health. It is characterized by collapse of the upper airway during sleep, due to the decrease in both basal and compensatory UA muscle activities. However, the leading treatment, continuous positive airway pressure, is often poorly tolerated. This review presents latest works focusing on novel interventions targeting upper airway muscles to alleviate OSA severity.

RECENT FINDINGS

In the last years, researchers have focused on the development of alternative treatment strategies targeting UA muscle activation, including pharmacological and nonpharmacological interventions.

SUMMARY

Among the nonpharmacological treatments, hypoglossal nerve stimulation aims to increase upper airway muscle phasic activity during sleep through electrical stimulation, while myofunctional therapy improves the activity and coordination of upper airway dilator muscles.Regarding OSA pharmacotherapy, recent findings strongly suggest that selective norepinephrine reuptake inhibitors such as atomoxetine and reboxetine, when administered with antimuscarinics such as oxybutynin, can alleviate OSA in most patients increasing pharyngeal dilator muscles activity during sleep. New combinations of norepinephrine reuptake inhibitors and antimuscarinics have further been explored with variable success and animal models showed that leptin, thyrothropin releasing hormone analogues and gene therapy hold potential for the future of OSA pharmacotherapy.

Sleep apnoea in the elderly: a great challenge for the future

Due in part to overall improvements in health, the population of elderly individuals is increasing rapidly. Similarly, obstructive sleep apnoea (OSA) is both gaining increased recognition and also increasing due to the worldwide obesity epidemic. The overlap of OSA and aging is large, but there is strong plausibility for causation in both directions: OSA is associated with pathological processes that may accelerate aging and aging related processes; aging may cause physical and neurological changes that predispose to obstructive (and central) apnoea. In addition, the common symptoms (e.g. excessive daytime somnolence, defects in memory and cognition), possible physiological consequences of OSA (e.g. accelerated cardiovascular and cerebrovascular atherosclerosis), and changes in metabolic and inflammatory markers overlap with the symptoms and associated conditions seen in aging. There is also the possibility of synergy in the effects of these symptoms and conditions on quality of life, as well as a need to separate treatable consequences of OSA from age-related complaints. Taken together, the above make it essential to review the interaction of OSA and aging, both proven and suspected. The present review examines some aspects of what is known and points to the need for further investigation of the relationships, given the large number of potentially affected subjects.

Improving CPAP Adherence in Adults With Obstructive Sleep Apnea Syndrome: A Scoping Review of Motivational Interventions

Objective: This scoping review aims to provide an accessible summary of available evidence on the efficacy of motivational interventions to increase adherence to Continuous Positive Airway Pressure (CPAP) among patients with Obstructive Sleep Apnea Syndrome (OSAS) and of their specific aspects and strategies by assessing adherence measures. Methods: A literature search was performed in PubMed, Scopus, Medline, PsycINFO, and Web of Science databases using the concepts of "obstructive sleep apnea syndrome," "continuous positive airway pressure," "motivational intervention," and "adherence." Rigorous inclusion criteria and screening by at least two reviewers were applied. Data were extracted to address the review aims and were presented as a narrative synthesis. Results: Search for databases produced 11 randomized controlled trials, all including naïve CPAP users. Findings showed that motivational interventions were more effective than usual care and educational programs in increasing adherence to CPAP, despite results were not always maintained over time across studies. Discussion: To our knowledge, this is the first scoping review of the literature aimed to explore the characteristics and impact of motivational interventions to promote adherence to CPAP in patients with OSAS. More research providing a detailed description of motivational strategies, and testing of their association with positive treatment outcomes via both direct and indirect measures are needed to increase awareness on active mechanisms of change.

Metrics of sleep apnea severity: beyond the apnea-hypopnea index

Obstructive sleep apnea (OSA) is thought to affect almost 1 billion people worldwide. OSA has well established cardiovascular and neurocognitive sequelae, although the optimal metric to assess its severity and/or potential response to therapy remains unclear. The apnea-hypopnea index (AHI) is well established; thus, we review its history and predictive value in various different clinical contexts. Although the AHI is often criticized for its limitations, it remains the best studied metric of OSA severity, albeit imperfect. We further review the potential value of alternative metrics including hypoxic burden, arousal intensity, odds ratio product, and cardiopulmonary coupling. We conclude with possible future directions to capture clinically meaningful OSA endophenotypes including the use of genetics, blood biomarkers, machine/deep learning and wearable technologies. Further research in OSA should be directed towards providing diagnostic and prognostic information to make the OSA diagnosis more accessible and to improving prognostic information regarding OSA consequences, in order to guide patient care and to help in the design of future clinical trials.

Obstructive sleep apnea and the risk of mortality in patients with lung cancer: a meta-analysis

PURPOSE

Prior reports have examined the relationship between obstructive sleep apnea (OSA) and the mortality rate of lung cancer. However, the findings remain controversial. The present meta-analysis was performed to assess the relationship between OSA and increased risk of mortality in patients with lung cancer.

METHODS

PubMed, Web of Science, and Embase were systematically searched for the correlative studies. Data were analyzed and pooled to evaluate odds ratios (ORs) of lung cancer mortality related to OSA.

RESULTS

From 249 identified studies, 3 met inclusion criteria and were analyzed, including 67 patients with lung cancer and comorbid OSA and 45 patients with lung cancer and no OSA. The meta-analysis indicated that OSA was not significantly correlated with mortality rate in lung cancer (OR = 2.005, 95% CI = 0.703 to 5.715, z = 1.30, p = 0.193). There was no significant publication bias according to Begg's tests (p = 0.296) and Egger's tests (p = 0.097).

CONCLUSION

This meta-analysis suggests that OSA is not significantly correlated with the mortality rate in lung cancer.

Sudden death in individuals with obstructive sleep apnoea: a systematic review and meta-analysis

Objectives

Over 1 billion individuals worldwide experience some form of sleep apnoea, and this number is steadily rising. Obstructive sleep apnoea (OSA) can negatively influence one’s quality of life and potentially increase mortality risk. However, the association between OSA and mortality has not been reliably estimated. This meta-analysis estimates the risk of all-cause and cardiovascular mortality in individuals with OSA.

Design

Systematic review and meta-analysis.

Data sources

MEDLINE, Cochrane Library, Scopus and Joanna Briggs Institute Evidence-Based Practice databases were searched from inception through 1 January 2020.

Eligibility criteria for selecting studies

We included observational studies assessing the association of sudden deaths in individuals with and without OSA.

Data extraction and synthesis

Two independent reviewers (AES and ESH) extracted data and assessed the risk of bias using the Newcastle-Ottawa Scale quality assessment tool. Data were pooled using the random-effects models and reported as risk ratios (RRs) with 95% CIs. Heterogeneity was quantified with I² statistic.

Results

We identified 22 observational studies (n=42 099 participants). The mean age was 62 years and 64% were men. OSA was associated with all-cause sudden death (RR=1.74, 95% CI: 1.44 to 2.10, I²=72%) and cardiovascular mortality (RR=1.94, 95% CI: 1.39 to 2.70, I²=32%). A marginally significant dose–response relationship between severity of OSA and the risk of death was observed (p for interaction=0.05): mild OSA (RR=1.16, 95% CI: 0.70 to 1.93), moderate OSA (RR=1.72, 95% CI: 1.11 to 2.67) and severe OSA (RR=2.87, 95% CI: 1.70 to 4.85). Meta-regression analysis showed that older age was a significant contributing factor in the relationship between OSA and mortality. The median study methodological quality was considered high.

Conclusions

OSA is a significant risk factor for all-cause mortality and cardiac mortality. Prevention and treatment strategies to optimise survival and quality of life in individuals with OSA are urgently needed.

PROSPERO registration number

CRD42020164941.

Cardiovascular Disease in Patients with Chronic Obstructive Pulmonary Disease, Obstructive Sleep Apnoea Syndrome and Overlap Syndrome

Chronic obstructive pulmonary disease (COPD) and obstructive sleep apnoea syndrome (OSAS) are among the most prevalent chronic respiratory disorders. Accumulating data suggest that there is a significant burden of cardiovascular disease (CVD) in patients with COPD and OSAS, affecting negatively patients' quality of life and survival. Overlap syndrome (OS), i.e. the co-existence of both COPD and OSAS in the same patient, has an additional impact on the cardiovascular system multiplying the risk of morbidity and mortality. The underlying mechanisms for the development of CVD in patients with either OSAS or COPD and OS are not entirely elucidated. Several mechanisms, in addition to smoking and obesity, may be implicated, including systemic inflammation, increased sympathetic activity, oxidative stress and endothelial dysfunction. Early diagnosis and proper management of these patients might reduce cardiovascular risk and improve patients' survival. In this review, we summarize the current knowledge regarding epidemiological aspects, pathophysiological mechanisms and present point-to-point specific associations between COPD, OSAS, OS and components of CVD, namely, pulmonary hypertension, coronary artery disease, peripheral arterial disease and stroke.

Obstructive Sleep Apnea: Treatment with Positive Airway Pressure

As in other adults, continuous positive airway pressure treatment for obstructive sleep apnea should be the mainstay of treatment. Benefits include improvements in sleepiness and quality of life, as well as improvements in hypertension control, arrhythmias, cardiovascular risk, and mortality. This article discusses issues in prescribing this treatment, including those related specifically to elderly individuals.

CPAP adherence is associated with reduced risk for stroke among older adult Medicare beneficiaries with obstructive sleep apnea

STUDY OBJECTIVES

To examine the impact of adherence to continuous positive airway pressure (CPAP) therapy on risk of stroke among a nationally representative sample of older adults with obstructive sleep apnea.

METHODS

We performed a retrospective cohort study among Medicare beneficiaries aged ≥ 65 years who were newly diagnosed with obstructive sleep apnea and had initiated CPAP (2009-2013). Monthly indicators of CPAP adherence included charges for machines, masks, or supplies and were summed over a 25-month follow-up to create a CPAP adherence variable. Stroke was modeled as a function of CPAP adherence using generalized estimating equations.

RESULTS

We found that 5,757 beneficiaries met the inclusion criteria and were included in the final sample. Of these, 407 (7%) experienced stroke. After adjusting for demographic and clinical characteristics, CPAP adherence was associated with a reduced risk of stroke (hazard ratio, 0.98; 95% confidence interval, 0.96-0.99) over 25 months, indicating a 2% reduction in risk of stroke for each month of CPAP adherence. When sensitivity analyses were performed to stratify results by time since the first CPAP charge, the protective effect remained significant for the 12- and 6-month but not the 3-month outcome models.

CONCLUSIONS

In this national analysis of older adult Medicare beneficiaries with obstructive sleep apnea, CPAP adherence was associated with significantly reduced risk of stroke.

Upper airway stimulation vs other upper airway surgical procedures for OSA: a meta-analysis

PURPOSE

The aim was to compare the outcomes of upper airway stimulation (Stim) and other upper airway surgical procedures (Surg) in the treatment of obstructive sleep apnea (OSA).

METHODS

Data sources included PubMed, Ovid MEDLINE, Cochrane Library, Web of Science, Scopus, and reference lists. Relevant articles were identified from various databases according to the PRISMA guidelines.

RESULTS

Five articles with a total of 990 patients were included. The mean cure rates in the Stim group and the Surg group was 63% and 22%, and the mean success rates was 86% and 51% which were higher in the Stim group (p < 0.001). The apnea-hypopnea index reduction was -23.9 events/ hour (MD, 95% CI -25.53, -22.29) in the Stim group and -15.5 events/hour (MD, 95% CI -17.50, -13.45) in the Surg group which was greater in the Stim group (P < 0.001). Epworth Sleepiness Scale decreased -4.9 (MD, 95% CI -5.45, -4.32) in the Stim group and -5.1 (MD 95% CI -5.88, -4.37) in the Surg group without significant difference between the groups (P = 0.62). Oxygen saturation nadir improvement was 8.5% (MD 95% CI 7.05%, 9.92%) in the Stim group and 2.2% (MD 95% CI-0.22%, 4.58%) in the Surg group which was higher in the Stim group (P < 0.001). Hospital stay and readmission rate were lower in the Stim group. The timing of follow-up ranged from 2 to 13 months.

CONCLUSION

Upper airway stimulation provides improved objective and similar subjective outcomes compared to other upper airway surgical procedures for selected patients with moderate to severe OSA with difficulty adhering to CPAP treatment. However, further studies are essential to confirm outcomes in the long term.

Sleep disordered breathing as a cause and consequence of stroke: A review of pathophysiological and clinical relationships

Stroke is the leading cause of death and disability globally. Sleep disordered breathing (SDB), a potentially modifiable risk factor of stroke, is highly prevalent in stroke survivors. Evidence supports a causal, bidirectional relationship between SDB and stroke. SDB may increase the risk of stroke occurrence and recurrence, and worsen stroke outcome. While SDB is associated with an increased incidence of hypertension and cardiac arrhythmias, both of which are traditional stroke risk factors, SDB is also an independent risk factor for stroke. A number of characteristics of SDB may increase stroke risk, including intermittent hypoxemia, sympathetic activation, changes in cerebral autoregulation, oxidative stress, systemic inflammation, hypercoagulability, and endothelial dysfunction. On the other hand, stroke may also cause new SDB or aggravate preexisting SDB. Continuous positive airway pressure treatment of SDB may have a beneficial role in reducing stroke risk and improving neurological outcome after stroke. The treatment should be considered as early as possible, particularly when SDB is present post-stroke. The goal of this review is to highlight the strong link between SDB and stroke and to raise awareness for practitioners to consider the possibility of SDB being present in all stroke survivors.

Age-specific markers of adiposity in patients with obstructive sleep apnea

OBJECTIVES

Adiposity can have varying effects on the individual depending upon its distribution pattern. We assessed age-related distribution of adipose tissue by anthropometric measures and bioelectrical impedance analysis, as well as their association with obstructive sleep apnea (OSA) severity.

METHODS

Participants were 169 elderly (aged ≥ 65 years) and 142 non-elderly (aged < 65 years) referred for overnight polysomnography. The associations between obesity parameters and apnea-hypopnea index (AHI) were determine by univariate and multivariate linear regression analyses. Area under receiver operating characteristic curve (AUC) was used to access the predicting performance of some parameters.

RESULTS

Compared with non-elderly, elderly showed higher conicity index and visceral adiposity (VA)/subcutaneous adiposity (SA), lower body mass index (BMI), neck circumference, waist circumference, hip circumference and SA. Multiple regression analyses revealed that VA and VA/SA were independently associated with AHI in elderly (explained 17.2% of the AHI ^0.5 variability), while BMI and VA/SA were independently associated with AHI in non-elderly (explained 25.9% of the AHI ^0.5 variability), after adjusting for age, sex, cigarette smoking, alcohol drinking and main comorbidities. In elderly, VA over 128 cm² and VA/SA less than 0.41 resulted in sensitivity, specificity and AUC of 0.382, 0.790, 0.580 and 0.176, 0.947, 0.553 in predicting moderate-to-severe OSA, respectively. In non-elderly, BMI over 24.7 kg/m² and VA/SA over 0.54 resulted in sensitivity, specificity and AUC of 0.883, 0.484, 0.704 and 0.550, 0.710, 0.667 in predicting moderate-to-severe OSA, respectively.

CONCLUSIONS

VA is strongly associated with OSA severity in elderly, independently of general obesity as per BMI standards, while general adiposity appears to be more strongly associated with OSA severity in non-elderly. Our study supports age-specific approaches should be developed with respect to prediction and treatment of OSA.

Socioeconomic Disparities in Positive Airway Pressure Adherence: An Integrative Review

Nonadherence with positive airway pressure (PAP) therapy impedes the effectiveness of treatment and increases risk of mortality. Disparities in PAP adherence as a function of socioeconomic status (SES) are not well understood. A literature search identified 16 original publications meeting inclusion criteria that described effects of SES factors on objective PAP adherence; 69% of these articles found evidence of lower adherence as a function of SES. This integrative review provides a structured summary of the findings, highlights factors that may contribute to disparities among adult PAP users, and identifies future directions to improve equity in the management of OSA.

Risk of mortality among patients with moderate to severe obstructive sleep apnea and diabetes mellitus: results from the SantOSA cohort

INTRODUCTION

Patients with obstructive sleep apnea (OSA) and comorbid diabetes mellitus (DM) are reported to have an increased risk of cardiovascular (CV) outcomes; however, data on CV mortality are scant.

AIM

This study aimed to evaluate if patients with comorbid OSA and DM have an increased risk of CV mortality that is higher than the two diseases in isolation.

METHODS

In this prospective cohort study, we included patients referred for a sleep study with and without DM at baseline. We developed four study groups as follows: group 1 (reference group), OSA (-) DM (-); group 2, OSA (-) DM (+); group 3, OSA (+) DM (-); group 4, OSA (+) DM (+). Intergroup differences were evaluated using the t test and χ² test, and multivariate analysis was performed using logistic regression. The incidence rates of CV mortality were calculated using the Kaplan-Meier (log-rank) model, and adjusted HRs were calculated using the Cox regression model.

RESULTS

A total of 1447 patients were included in the analysis-group 1: 441 participants; group 2: 141 participants; group 3: 736 participants; group 4: 151 participants. The mean follow-up was 5 years. The association between OSA + DM showed an independent risk of incident CV mortality (HR 2.37, CI 1.16-4.82, p = 0.02) and an increased prevalence of coronary heart disease (OR 3.44, CI 1.73-5.59, p < 0.01). In addition, T90% was also associated with CV mortality.

CONCLUSION

The coexistence of OSA + DM was associated with an independent risk of CV mortality. In addition, T90% was also associated with CV mortality.

The effects of continuous positive airway pressure and mandibular advancement therapy on metabolic outcomes of patients with mild obstructive sleep apnea: a randomized controlled study

BACKGROUND

Moderate and severe obstructive sleep apnea (OSA) have been independently associated with dyslipidemia. The results of metabolic improvement with continuous positive airway pressure (CPAP) have been controversial. Less evidence exists regarding this issue in mild OSA. A current treatment for mild OSA is mandibular advancement device (MAD) therapy, but its effectiveness on the metabolic profile needs to be compared with CPAP. The purpose of this study was to compare MAD vs CPAP vs no treatment on the metabolic profile during 6 and 12 months of follow-up in patients with mild OSA.

METHODS

The inclusion criteria were patients with mild OSA, both genders, ages 18 to 65 years, and body mass index (BMI) of < 35 Kg/m². Patients were randomized in 3 groups (CPAP, MAD, and control). The evaluations included physical examination, metabolic profile, and full polysomnography at baseline, 6 months, and 12 months of follow-up.

RESULTS

Seventy-nine patients with mild OSA were randomized in three treatment groups, with mean age (± SD) of 47 ± 9 years, 54% men, and AHI 9.5 ± 2.9 events/h. MAD and CPAP reduced AHI at 6 and 12 months compared to the control group. MAD adherence was higher than CPAP at 6 and 12 months. Despite lower adherence compared to MAD, CPAP was more effective in reducing total cholesterol over 12 months (baseline 189.3 ± 60.2 mg/dl to 173.4 ± 74.3 mg/dl) and low-density lipoprotein cholesterol (LDL-c, baseline 112.8 ± 54.9 mg/dl to 94.5 ± 67.4 mg/dl).

CONCLUSIONS

After 1 year of treatment, CPAP was superior to MAD in reducing total cholesterol and LDL-c in patients with mild OSA.

Long-term All-Cause Mortality Risk in Obstructive Sleep Apnea Using Hypopneas Defined by a ≥3 Percent Oxygen Desaturation or Arousal

STUDY OBJECTIVES

Some prior studies have demonstrated an increase in mortality associated with obstructive sleep apnea (OSA) utilizing a definition of OSA that requires a minimum 4% oxygen desaturation to identify a hypopnea. No large community-based studies have determined the risk of long-term mortality with OSA with hypopneas defined by a ≥3% O2 desaturation or arousal (AHI3%A).

METHODS

Data from 5591 Sleep Heart Health Study participants without prevalent cardiovascular disease at baseline who underwent polysomnography were analyzed regarding OSA diagnosed using the AHI3%A criteria and all-cause mortality over a mean follow up period of 10.9±3.2 years.

RESULTS

There were 1050 deaths in this group during the follow-up period. A Kaplan-Meir plot of survival revealed a reduction in survival with increasing AHI severity. Cox proportional hazards regression models revealed significantly increased all-cause mortality risk with increasing AHI, hazard ratio (HR, 95% CI) 1.13 (1.04-1.23), after adjusting for age, sex, race, BMI, cholesterol, HDL, self-reported hypertension and/or diabetes and smoking status. In categorical models, the mortality risk was significantly higher with severe OSA [adjusted HR 1.38 (1.09-1.76)]. When stratified by gender or age, severe OSA was associated with increased risk of death in men [adjusted HR 1.14 (1.01-1.28)] and in those <70 years of age [adjusted HR 1.51 (1.02-2.26)]. In contrast, AHI severity was not associated with increased mortality in women or those ≥70 years of age in fully adjusted models.

CONCLUSION

Severe AHI3%A OSA is associated with significantly increased mortality risk, especially in men and those <70 years of age.

SAS CARE 2 - a randomized study of CPAP in patients with obstructive sleep disordered breathing following ischemic stroke or transient ischemic attack

Objective/background

The benefit of Continuous Positive Airway Pressure (CPAP) treatment following ischemic stroke in patients with obstructive sleep-disordered breathing (SDB) is unclear. We set out to investigate this open question in a randomized controlled trial as part of the SAS-CARE study.

Patients/methods.

Non-sleepy patients (ESS < 10) with ischemic stroke or transient ischemic attack (TIA) and obstructive SDB (AHI ≥ 20) 3 months post-stroke were randomized 1:1 to CPAP treatment (CPAP+) or standard care. Primary outcome was the occurrence of vascular events (TIA/stroke, myocardial infarction/revascularization, hospitalization for heart failure or unstable angina) or death within 24 months post-stroke. Secondary outcomes included Modified Rankin Scale (mRS) and Barthel Index.

Results

Among 238 SAS-CARE patients 41 (17%) non-sleepy obstructive SDB patients were randomized to CPAP (n = 19) or standard care (n = 22). Most patients (80%) had stroke and were males (78%), mean age was 64 ± 7 years and mean NIHSS score 0.6 ± 1.0 (range: 0–5). The primary endpoint was met by one patient in the standard care arm (a new stroke). In an intent-to treat analysis disregarding adherence, this corresponds to an absolute risk difference of 4.5% or an NNT = 22. mRS and Barthel Index were stable and similar between arms. CPAP adherence was sufficient in 60% of evaluable patients at month 24.

Conclusion

No benefit of CPAP started three months post-stroke was found in terms of new cardio- and cerebrovascular events over 2 years. This may be related to the small size of this study, the mild stoke severity, the exclusion of sleepy patients, the delayed start of treatment, and the overall low event rate.

•

No benefit of CPAP started 3 months post-stroke was found.

•

A sufficient CPAP compliance was observed over 2 years in 60% of patients.

•

Studies of CPAP in mild stroke need to be large and include long-term outcomes.

Amelioration of sleep-disordered breathing with supplemental oxygen in older adults

Elderly adults demonstrate increased propensity for breathing instability during sleep compared with younger adults, and this may contribute to increased prevalence of sleep-disordered breathing (SDB) in this population. Hence, in older adults with SDB, we examined whether addition of supplemental oxygen (O₂) will stabilize breathing during sleep and alleviate SDB. We hypothesized that exposure to supplemental O₂ during non-rapid eye movement (NREM) sleep will stabilize breathing and will alleviate SDB by reducing ventilatory chemoresponsiveness and by widening the carbon dioxide (CO₂) reserve. We studied 10 older adults with mild-to-moderate SDB who were randomized to undergo noninvasive bilevel mechanical ventilation with exposure to room air or supplemental O₂ (Oxy) to determine the CO₂ reserve, apneic threshold (AT), and controller and plant gains. Supplemental O₂ was introduced during sleep to achieve a steady-state O₂ saturation ≥95% and fraction of inspired O₂ at 40%-50%. The CO₂ reserve increased significantly during Oxy versus room air (-4.2 ± 0.5 mmHg vs. -3.2 ± 0.5 mmHg, P = 0.03). Compared with room air, Oxy was associated with a significant decline in the controller gain (1.9 ± 0.4 L/min/mmHg vs. 2.5 ± 0.5 L/min/mmHg, P = 0.04), with reductions in the apnea-hypopnea index (11.8 ± 2.0/h vs. 24.4 ± 5.6/h, P = 0.006) and central apnea-hypopnea index (1.7 ± 0.6/h vs. 6.9 ± 3.9/h, P = 0.03). The AT and plant gain were unchanged. Thus, a reduced slope of CO₂ response resulted in an increased CO₂ reserve. In conclusion, supplemental O₂ reduced SDB in older adults during NREM sleep via reduction in chemoresponsiveness and central respiratory events.NEW & NOTEWORTHY This study demonstrates for the first time in elderly adults without heart disease that intervention with supplemental oxygen in the clinical range will ameliorate central apneas and hypopneas by decreasing the propensity to central apnea through decreased chemoreflex sensitivity, even in the absence of a reduction in the plant gain. Thus, the study provides physiological evidence for use of supplemental oxygen as therapy for mild-to-moderate SDB in this vulnerable population.

Mortality and morbidity in obstructive sleep apnoea-hypopnoea syndrome: results from a 30-year prospective cohort study

Background

Obstructive sleep apnoea–hypopnoea syndrome (OSAHS) carries substantial negative health consequences. This study examines factors affecting mortality and morbidity according to continuous positive airway pressure (CPAP) use and predictors affecting CPAP adherence in a longitudinal cohort of OSAHS patients.

Materials and methods

This prospective, cohort study comprised 4502 patients who were diagnosed with OSAHS at a tertiary sleep disorders centre between 1982 and 2003. Of these, 1174 patients completed follow-up in 2012. Data collected included anthropometric, sleep and demographic characteristics, including comorbidities, ongoing medications and CPAP adherence. Patients were followed up for an average of 14.8±3.7 years.

Results

Imputation analysis showed that long-term CPAP users (>5 years) were 5.63 times more likely to be alive at study end than non-CPAP users (95% CI: 4.83–6.58, p<0.001) and 1.74-times more likely than short-term CPAP users (≤5 years) (95% CI: 1.49–2.02, p<0.001). Females had a significantly higher mortality rate during the follow-up period (26.8% versus 19.6%, p<0.001). Respiratory mortality was more common in patients with OSAHS, in particular those who did not use CPAP, compared to the general population (17.2% versus 12.2%, p=0.002 respectively), whereas deaths from cancer were less common compared to the general population (16.2% versus 25.6%, p<0.001). Compared to CPAP users, non-CPAP-users had a significantly increased incidence of type II diabetes mellitus (DMII) (27.9% versus 18.7%, p=0.003), ischaemic heart disease (IHD) (25.5% versus 12.7%, p<0.001) and myocardial infarction (MI) (14.7% versus 4.2%, p<0.001) at long-term follow-up.

Conclusions

Long-term CPAP use in men and women with OSAHS reduces mortality and decreases the incidence of DMII and cardiovascular disease.

In this first long-term prospective cohort study to use imputation analysis in OSAHS patients, all-cause morbidity and mortality were significantly reduced in long-term CPAP users (>5 years), and equivalent for both males and femaleshttps://bit.ly/3cKL2HK

Insomnia and daytime sleepiness predict 20-year mortality in older male adults: data from a population-based study

Data regarding the possible relationship of insomnia and EDS with mortality are inconclusive. The aim of this study was to investigate the association between these sleep complaints and the risk of long-term (20 years) all-cause mortality in older adults. Between April 2000 and March 2001, 750 subjects aged 65 years and older, who resided in the seventh district of Udine, were recruited. Data on sociodemographic characteristics, past medical history, and pharmacological treatment were collected. Dementia was diagnosed using a comprehensive neurological and neuroradiological assessment. Older adults were interviewed by neuropsychologists trained in sleep disturbances in order to assess the presence of sleep complaints. Vital status was followed over 20 years until March 2020. Older male adults affected by insomnia and EDS were significantly more likely to die over the follow-up period. Indeed, males reporting poor sleep and daytime somnolence had a 60% and 48% higher chance of dying than subjects who were not affected by these sleep complaints, respectively. The HR was attenuated after adjusting for confounding variables among insomniacs, whereas that of somnolent men strengthened. Differently from men, insomnia and EDS did not have any impact on mortality in older women. In conclusion, older male adults affected by insomnia and EDS had a significant increased risk of mortality, which is independent of cancer, depression, dementia, cardiovascular diseases, and sleeping pill use.

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

Importance

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

Objective

To investigate the association between PAP prescription and mortality.

Design, Setting, and Participants

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

Exposures

Self-reported use of PAP.

Main Outcomes and Measures

All-cause mortality.

Results

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

Conclusions and Relevance

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