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Weinstock TG, Redline S. Comparative effectiveness research in obstructive sleep apnea: bridging gaps between efficacy studies and clinical practice. J Comp Eff Res 2014; 1:83-105. [PMID: 24237298 DOI: 10.2217/cer.11.12] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Comparative effectiveness research encompasses research that compares two interventions to each other, and takes place in real-world settings without strict inclusion and exclusion criteria, according to the established standard of care. There is a need for comparative evaluations of the treatments for obstructive sleep apnea, a disease associated with increased cardiovascular risk, stroke and metabolic derangement. This article reviews the recent, representative literature that addresses obstructive sleep apnea intervention and treatment, paradigms for diagnosis and randomized control trials addressing the efficacy of interventions, in an effort to demonstrate examples of both traditional observational and randomized control trials, as well as to illustrate the considerable overlap between some traditional studies and comparative effectiveness research. Despite methodological challenges, the potentially large clinical and public health impact of obstructive sleep apnea, accompanied by considerable cost, mandates that randomized controlled trials and comparative effectiveness research be systematically applied to identify both the efficacy and effectiveness of alternative diagnosis and treatment strategies.
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Affiliation(s)
- Tanya G Weinstock
- Programs in Sleep & Cardiovascular Medicine & Sleep Medicine Epidemiology, Division of Sleep Medicine, Brigham & Women's Hospital & Beth Israel Deaconess Medical Center, Boston, MA, USA.
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Jurysta F, Kempenaers C, Lanquart JP, Noseda A, van de Borne P, Linkowski P. Long-term CPAP treatment partially improves the link between cardiac vagal influence and delta sleep. BMC Pulm Med 2013; 13:29. [PMID: 23628083 PMCID: PMC3685543 DOI: 10.1186/1471-2466-13-29] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 04/18/2013] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Continuous positive airway pressure (CPAP) treatment improves the risk of cardiovascular events in patients suffering from severe sleep apnea-hypopnea syndrome (SAHS) but its effect on the link between delta power band that is related to deep sleep and the relative cardiac vagal component of heart rate variability, HF(nu) of HRV, is unknown. Therefore, we tested the hypothesis that CPAP restores the link between cardiac autonomic activity and delta sleep across the night. METHODS Eight patients suffering from severe SAHS before and after 4 ± 3 years of nasal CPAP treatment were matched with fourteen healthy controls. Sleep EEG and ECG were analysed to obtain spectral sleep and HRV components. Coherence analysis was applied between HF(nu) and delta power bands across the first three sleep cycles. RESULTS Sleep characteristics and spectral HRV components were similar between untreated patients, treated patients and controls, with the exception of decreased Rapid Eye Movement duration in untreated patients. Coherence and gain values between HF(nu) and delta EEG variability were decreased in untreated patients while gain values normalized in treated patients. In patients before and during long-term CPAP treatment, phase shift and delay between modifications in HF(nu) and delta EEG variability did not differ from controls but were not different from zero. In healthy men, changes in cardiac vagal activity appeared 9 ± 7 minutes before modifications in delta sleep. CONCLUSIONS Long-term nasal CPAP restored, in severe SAHS, the information between cardiovascular and sleep brainstem structures by increasing gain, but did not improve its tightness or time shift.
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Affiliation(s)
- Fabrice Jurysta
- Sleep Laboratory and Laboratory of Psychiatric Research, Department of Psychiatry, Erasme Academic Hospital - ULB, Brussels, Belgium
| | - Chantal Kempenaers
- Sleep Laboratory and Laboratory of Psychiatric Research, Department of Psychiatry, Erasme Academic Hospital - ULB, Brussels, Belgium
| | - Jean-Pol Lanquart
- Sleep Laboratory and Laboratory of Psychiatric Research, Department of Psychiatry, Erasme Academic Hospital - ULB, Brussels, Belgium
| | - André Noseda
- Chest Department, Erasme Academic Hospital-ULB, Brussels, Belgium
| | - Philippe van de Borne
- Department of Cardiology and Hypertension Clinic, Erasme Academic Hospital - ULB, Brussels, Belgium
| | - Paul Linkowski
- Sleep Laboratory and Laboratory of Psychiatric Research, Department of Psychiatry, Erasme Academic Hospital - ULB, Brussels, Belgium
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Abstract
Data from animal and human studies provide a biological plausibility to the notion that obstructive sleep apnea activates pathways that lead to insulin resistance, atherosclerosis and hypertension. Sleep apnea thus activates the same pathways as does obesity. That obstructive sleep apnea is a risk factor for cardiovascular disease is supported by epidemiological association studies. Longitudinal cohort studies also provide evidence that patients with untreated severe sleep apnea have an increased rate of cardiovascular events. But these studies, while highly suggestive, do not provide the evidence needed to convince the skeptic. This would only be obtained by randomized treatment trials with hard cardiovascular endpoints such as cardiac events and deaths. While such studies are in the planning stages, they will be challenging. There are issues about randomizing individuals with severe sleep apnea and excessive sleepiness into no therapy, since they are at known increased risk for car crashes. Thus, lack of therapy puts others on the road at risk as well as the subject with sleep apnea. There is, moreover, the concern that treating obstructive sleep apnea in very obese individuals will have little impact, since any effect of therapy for OSA will be overwhelmed by the effects of obesity itself. Data from randomized treatment trials for cardiovascular endpoints will likely not be available for many years. In the interim, physicians need to consider how to treat such patients. It is proposed that given that CPAP treatment for obstructive sleep apnea is highly effective and essentially totally safe, and that the evidence is suggestive that sleep apnea is a risk factor for cardiovascular disease, then we propose all patients with severe sleep apnea should be treated to reduce cardiovascular risk.
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Sadikot S. A clinical overview: Obstructive sleep apnea and hypertension. Diabetes Metab Syndr 2008. [DOI: 10.1016/j.dsx.2007.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Sadikot S. An overview: Obstructive Sleep Apnea and the Metabolic Syndrome: Should “X” be changed to “Zzz…Zzzz….Zzzzzzzzz….Zzz”? Diabetes & Metabolic Syndrome: Clinical Research & Reviews 2007. [DOI: 10.1016/j.dsx.2007.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Buchner NJ, Sanner BM, Borgel J, Rump LC. Continuous positive airway pressure treatment of mild to moderate obstructive sleep apnea reduces cardiovascular risk. Am J Respir Crit Care Med 2007; 176:1274-80. [PMID: 17673692 DOI: 10.1164/rccm.200611-1588oc] [Citation(s) in RCA: 207] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
RATIONALE Obstructive sleep apnea (OSA) is linked to increased cardiovascular risk, but the impact of mild forms of OSA and their treatment on cardiovascular outcomes remains controversial. OBJECTIVES To prospectively investigate cardiovascular outcomes in treated versus untreated patients with OSA. METHODS Consecutive sleep laboratory patients with all degrees of OSA were included. Endpoints were nonfatal (myocardial infarction, stroke, and acute coronary syndrome requiring revascularization procedures) and fatal (death from myocardial infarction or stroke) cardiovascular events. MEASUREMENTS AND MAIN RESULTS Comparison of event-free survival rates in treated versus untreated patients (Kaplan-Meier estimates, log-rank test). Of 449 patients enrolled (age, 56.0 +/- 10.5 years; body mass index, 30.8 +/- 5.4 kg/m(2)), 364 patients received OSA treatment, and 85 patients remained untreated. Median follow-up was 72.0 months (range, 1-156). Mean apnea-hypopnea index before treatment was 30.9 +/- 21.8/hour in treated and 15.3 +/- 13.0/hour in untreated patients, but there were no differences in cardiovascular comorbidities or risk factors. In patients with mild-moderate OSA (n = 288), events were more frequent in untreated patients (estimated event-free survival at 10 yr, 51.8 vs. 80.3% [P < 0.001]; absolute risk reduction, 28.5%; number needed to treat to prevent one event/10 yr, 3.5). After adjustment for age, gender, cardiovascular risk factors, and comorbidities at baseline, OSA treatment was an independent predictor for events (hazard ratio, 0.36; 95% confidence interval, 0.21-0.62; P < 0.001). CONCLUSIONS OSA treatment was associated with a cardiovascular risk reduction of 64% independent from age and preexisting cardiovascular comorbidities. OSA treatment should be considered for primary and secondary cardiovascular prevention, even in milder OSA.
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Affiliation(s)
- Nikolaus J Buchner
- Department of Internal Medicine I, Marienhospital Herne, Ruhr University Bochum, Hoelkeskampring 40, D-44625 Herne, Germany.
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Grunstein RR, Stenlöf K, Hedner JA, Peltonen M, Karason K, Sjöström L. Two year reduction in sleep apnea symptoms and associated diabetes incidence after weight loss in severe obesity. Sleep 2007; 30:703-10. [PMID: 17580591 PMCID: PMC1978357 DOI: 10.1093/sleep/30.6.703] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
STUDY OBJECTIVES To evaluate the effect of bariatric surgery on sleep apnea symptoms and obesity-associated morbidity in patients with severe obesity. DESIGN Prospective study. SETTING University hospitals and community centers in Sweden. INTERVENTION We investigated the influence of weight loss surgery (n=1729) on sleep apnea symptoms and obesity-related morbidity using a conservatively treated group (n=1748) as a control. MEASUREMENTS AND RESULTS Baseline BMI in surgical group (42.2+/-4.4 kg/m(2)) and control group (40.1+/-4.6 kg/m(2)) changed -9.7+/-5 kg/m(2) and 0+/-3 kg/m(2), respectively, at 2-year follow-up. In the surgery group, there was a marked improvement in all obstructive sleep apnea (OSA) symptoms compared with the control group (P <0.001). Persistence of snoring (21.6 vs 65.5%, adjusted OR 0.14, 95% CI 0.10-0.19) and apnea (27.9 vs 71.3%, adjusted OR 0.16, 95% I 0.10-0.23) were much less in the surgery group compared with controls. Compared with subjects with no observed apnea at follow-up (n=2453), subjects who continued to have or developed observed apnea (n=404) had a higher incidence of diabetes (adjusted OR 2.03, 95% CI 1.19-3.47) and hypertriglyceridemia (adjusted OR 1.86, 95% CI 1.07-3.25) but not hypertension (adjusted OR 1.09, 95% CI 0.65-1.83) or hypercholesterolemia (adjusted OR 0.91, 95% CI 0.53-1.58). CONCLUSION Bariatric surgery results in a marked improvement in sleep apnea symptoms at 2 years. Despite adjustment for weight change and baseline central obesity, subjects reporting loss of OSA symptoms had a lower 2-year incidence of diabetes and hypertriglyceridemia. Improvement in OSA in patients losing weight may provide health benefits in addition to weight loss alone.
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Affiliation(s)
- Ronald R Grunstein
- Department of Puhnlmonary and Sleep Medicine, Sahlgrenska University Hospital, Göteborg, Sweden.
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Svendsen M, Blomhoff R, Holme I, Tonstad S. The effect of an increased intake of vegetables and fruit on weight loss, blood pressure and antioxidant defense in subjects with sleep related breathing disorders. Eur J Clin Nutr 2007; 61:1301-11. [PMID: 17268408 DOI: 10.1038/sj.ejcn.1602652] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess the effect of an increased consumption of vegetables and fruit on body weight, risk factors for cardiovascular disease (CVD) and antioxidant defense in obese patients with sleep-related breathing disorders (SRBD). DESIGN Randomized, controlled trial of an intervention to increase the intake of vegetables to 400 g/day and fruit to 300 g/day. Dietary intake was calculated from a food frequency questionnaire. Antioxidant status was assessed with the ferric-reducing/antioxidant power (FRAP) assay. Plasma carotenoids were biomarkers for the intake of vegetables and fruit. SETTING A hospital clinic preventing risk factors for CVD. SUBJECTS Subjects were 103 men and 35 women with a body mass index of 36.7+/-5.8 kg/m(2) of which 57 (86%) in the control and 68 (94%) in the intervention group completed the study. INTERVENTION Group-based behavioral program during 3 months. RESULTS The mean between group differences in body weight was -2.0% (95% CI -3.6, -0.5), P<0.0001. The mean between group difference in systolic and diastolic blood pressure (BP) was -7.1 mm Hg (95% CI: -11.6, -2.6), P=0.0022 and -3.9 mm Hg (95% CI: -7.0, -0.9), P=0.0120, respectively. The mean change in daily intake of vegetables and fruit was 12 g (95% CI: -33, 57) and -4 g (95% CI: -79, 71) versus 245 g (95% CI: 194, 296) and 248 g (95% CI: 176, 320) in the control and intervention groups, respectively. This was reflected in higher concentrations of alpha-carotene and beta-carotene. No change in FRAP was seen. In a multiple regression analysis the change in intake of vegetables was a significant contributor (R(adj)(2)=0.073 (95% CI: 0.019, 0.214)) to the change in weight. CONCLUSION Targeted dietary advice to increase the intake of vegetables and fruit among subjects with SRBD contributed to weight reduction and reduced systolic and diastolic BP, but had no effect on antioxidant defense measured with FRAP.
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Affiliation(s)
- M Svendsen
- Department of Preventive Cardiology, Ullevål University Hospital, Oslo, Norway.
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Giles TL, Lasserson TJ, Smith BJ, White J, Wright J, Cates CJ. Continuous positive airways pressure for obstructive sleep apnoea in adults. Cochrane Database Syst Rev 2006:CD001106. [PMID: 16437429 DOI: 10.1002/14651858.cd001106.pub2] [Citation(s) in RCA: 265] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Obstructive sleep apnoea is the periodic reduction (hypopnoea) or cessation (apnoea) of breathing due to narrowing or occlusion of the upper airway during sleep. The main symptom is daytime sleepiness and it has been suggested it is linked to premature death, hypertension, ischaemic heart disease, stroke and road traffic accidents. OBJECTIVES The main treatment for sleep apnoea is with the use of continuous positive airways pressure (CPAP), which requires a flow generator and mask. These are used at night to prevent apnoea, hypoxia and sleep disturbance. The objective was to assess the effects of CPAP in the treatment of obstructive sleep apnoea in adults. SEARCH STRATEGY We searched the Cochrane Airways Group Trials Register and reference lists of articles. We consulted experts in the field. Searches were current to July 2005. SELECTION CRITERIA We included randomised trials comparing nocturnal CPAP with an inactive control or oral appliances in adults with obstructive sleep apnoea (an apnoea and hypopnoea index greater than five per hour). Trials had a minimum intervention period of two weeks. DATA COLLECTION AND ANALYSIS Trial quality was assessed and two review authors extracted data independently. Study authors were contacted for missing information. Parallel and crossover group trials were analysed separately. MAIN RESULTS Thirty-six trials involving 1718 people met the inclusion criteria. Study quality was mixed. Compared with control, CPAP showed significant improvements in objective and subjective sleepiness and several quality of life, cognitive function and depression measures (parallel-group studies: Epworth sleepiness scale (ESS) -3.83 units, 95% CI -4.57 to -3.09; crossover studies: ESS -1.84 units, 95% CI -2.57 to -1.11). Twenty-four hour systolic and diastolic blood pressures were lower with CPAP compared with control (parallel-group trials). Compared with oral appliances, CPAP significantly reduced the apnoea and hypopnoea index (crossover studies: -7.97 events/hr, 95% CI -9.56 to -6.38) and improved sleep efficiency (crossover studies: 2.31%, 95% CI 0.02 to 4.6) and minimum oxygen saturation (4.14%, 95% CI 3.25 to 5.03). Responders to both treatments expressed a strong preference for the oral appliance. However, participants were more likely to withdraw on OA than on CPAP therapy. AUTHORS' CONCLUSIONS CPAP is effective in reducing symptoms of sleepiness and improving quality of life measures in people with moderate and severe obstructive sleep apnoea (OSA). It is more effective than oral appliances in reducing respiratory disturbances in these people but subjective outcomes are more equivocal. Certain people tend to prefer oral appliances to CPAP where both are effective. This could be because they offer a more convenient way of controlling OSA. Short-term data indicate that CPAP leads to lower blood pressure than in controls. Long-term data are required for all outcomes in order to determine whether the initial benefits seen in short-term clinical trials persist.
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Affiliation(s)
- T L Giles
- Queen Elizabeth Hospital, Respiratory Medicine, 28 Woodville Rd, Woodville South, Adelaide, South Australia, Australia, 5011.
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Abstract
Since the original clarification of the obstructive nature of obstructive sleep apnea (OSA) in 1965, much has been learned about the disorder. It is a condition with a high prevalence with obesity as a major risk factor. It aggregates in families, a relationship that is not simply explained by obesity. Premenopausal women are relatively protected from the disorder because OSA is uncommon in this group. Its prevalence in women rises after menopause. Although OSA is a risk factor for excessive sleepiness, there is developing evidence that it is also a risk factor for hypertension, acute cardiovascular events, and insulin resistance. The first line of therapy is nasal continuous positive airway pressure. Data as to the efficacy of continuous positive airway pressure in severe OSA have come from randomized, placebo-controlled clinical trials with the endpoints being sleepiness, quality of life, and 24-h ambulatory blood pressure. Data are currently less convincing for treatment outcomes in mild to moderate OSA, and new clinical trials to assess outcomes in this group are underway. Thus, even though this field only began toward the end of the first century of the American Thoracic Society, substantial progress has been made, and OSA has increasingly emerged as a major public health concern.
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Affiliation(s)
- Allan I Pack
- Center for Sleep and Respiratory Neurobiology, 125 South 31st Street, Room 2120, Philadelphia, PA 19104-3403, USA.
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Chez l’insuffisant cardiaque, l’existence d’apnées du sommeil ne semble pas modifier la mortalité à long terme. Rev Mal Respir 2005. [DOI: 10.1016/s0761-8425(05)73040-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
This brief review addresses the characteristics, lability and the mechanisms underlying the hypocapnic-induced apnoeic threshold which is unmasked during NREM sleep. The role of carotid chemoreceptors as fast, sensitive detectors of dynamic changes in CO2 is emphasized and placed in historical context of the long-held debate over central vs. peripheral contributions to CO2 sensing and to apnoea. Finally, evidence is presented which points to a significant role for unstable, central respiratory motor output as a significant contributor to upper airway narrowing and obstruction during sleep.
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Affiliation(s)
- Jerome A Dempsey
- John Rankin Laboratory of Pulmonary Medicine, University of Wisconsin, 1300 University Avenue, Rm. 4245 MSC, Madison, WI, USA.
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