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Shiina K. Obstructive sleep apnea -related hypertension: a review of the literature and clinical management strategy. Hypertens Res 2024:10.1038/s41440-024-01852-y. [PMID: 39210083 DOI: 10.1038/s41440-024-01852-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 07/24/2024] [Accepted: 07/30/2024] [Indexed: 09/04/2024]
Abstract
Obstructive Sleep Apnea (OSA) and hypertension have a high rate of co-occurrence, with OSA being a causative factor for hypertension. Sympathetic activity due to intermittent hypoxia and/or fragmented sleep is the most important mechanisms triggering the elevation in blood pressure in OSA. OSA-related hypertension is characterized by resistant hypertension, nocturnal hypertension, abnormal blood pressure variability, and vascular remodeling. In particular, the prevalence of OSA is high in patients with resistant hypertension, and the mechanism proposed includes vascular remodeling due to the exacerbation of arterial stiffness by OSA. Continuous positive airway pressure therapy is effective at lowering blood pressure, however, the magnitude of the decrease in blood pressure is relatively modest, therefore, patients often need to also take antihypertensive medications to achieve optimal blood pressure control. Antihypertensive medications targeting sympathetic pathways or the renin-angiotensin-aldosterone system have theoretical potential in OSA-related hypertension, Therefore, beta-blockers and renin-angiotensin system inhibitors may be effective in the management of OSA-related hypertension, but current evidence is limited. The characteristics of OSA-related hypertension, such as nocturnal hypertension and obesity-related hypertension, suggests potential for angiotensin receptor-neprilysin inhibitor (ARNI), sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucose-dependent insulinotropic polypeptide receptor/ glucagon-like peptide-1 receptor agonist (GIP/GLP-1 RA). Recently, OSA has been considered to be caused not only by upper airway anatomy but also by several non-anatomic mechanisms, such as responsiveness of the upper airway response, ventilatory control instability, and reduced sleep arousal threshold. Elucidating the phenotypic mechanisms of OSA may potentially advance more personalized hypertension treatment strategies in the future. Clinical characteristics and management strategy of OSA-related hypertension. OSA obstructive sleep apnea, BP blood pressure, ABPM ambulatory blood pressure monitoring, CPAP continuous positive airway pressure, LVH left ventricular hypertrophy, ARB: angiotensin II receptor blocker, SGLT2i Sodium-glucose cotransporter 2 inhibitors, ARNI angiotensin receptor-neprilysin inhibitor, CCB calcium channel blocker, GIP/GLP-1 RA glucose-dependent insulinotropic polypeptide receptor and glucagon-like peptide-1 receptor agonist.
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Affiliation(s)
- Kazuki Shiina
- Department of Cardiology, Tokyo Medical University, Tokyo, Japan.
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Luo ZR, Wang ZS, Chen YX, Chen LW. Outcomes of endovascular therapy for Stanford type B aortic dissection in patients with sleep apnea syndrome. J Vasc Surg 2024:S0741-5214(24)01340-5. [PMID: 38925349 DOI: 10.1016/j.jvs.2024.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 05/23/2024] [Accepted: 06/15/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVE This study aimed to determine the influences of varying severity of sleep apnea syndrome (SAS) on the outcomes after thoracic endovascular aorta repair (TEVAR) in patients with Stanford type B aortic dissection (TBAD). METHODS This observational study focused on individuals with TBAD plus SAS who received TEVAR between January 2018 and December 2022. Patients were divided into groups according to the results of the portable sleep-breathing monitoring systems: mild SAS (MSAS) and moderate-to-severe SAS (MSSAS). Clinical profiles were collected and analyzed. RESULTS A total of 121 cases with TBAD plus SAS who underwent TEVAR were enrolled in this study. Two groups were formed by stratifying these cases: MSAS (74 cases) and MSSAS (47 cases). The MSSAS cases were found to be older relative to MSAS cases (51.7 ± 8.3 years vs 57.1 ± 12.8 years; P = .012) and had a higher body mass index (BMI; 25.7 ± 2.3 kg/m2vs 27.0 ± 2.3 kg/m2; P = .038). The investigation did not find any appreciable differences between the MSAS and MSSAS groups in terms of complications (endoleak, P = .403; stent-induced new entry, P >.999; and stent displacement: P >.999). However, the MSSAS group exhibited a significantly higher overall mortality rate compared with the MSAS group (log-rank P = .027). The tendency continued when examining cases with Marfan syndrome combined with MSSAS, where the overall mortality rate was significantly greater compared with Marfan syndrome cases with MSAS (log-rank P = .037). The absence of a significant difference was noteworthy in the freedom from reintervention between the MSAS and MSSAS groups (log-rank P = .278). The overall mortality rate was significantly higher in MSSAS group even after adjusting for varying potential confounders in the multivariate cox regression analysis (hazard ratio [HR], 1.875; 95% confidence interval [CI], 1.238-2.586; P = .012). A markedly higher rate of distal stent dilation in the MSSAS group was also observed compared with the MSAS group (HR, 2.5 mm/year [95% CI, 2-3 mm/year] vs HR, 4 mm/year [95% CI, 2.0-5.5 mm/year]; P = .029). CONCLUSIONS MSSAS is associated with a significantly higher risk of overall mortality and dilation rate of the distal stent after TEVAR for TBAD patients. Hence, aggressive efforts to reverse the severity of SAS in time in these individuals seem to be necessary.
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Affiliation(s)
- Zeng-Rong Luo
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, PR China; Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province, PR China
| | - Zhi-Sheng Wang
- Department of Cardio-Thoracic Surgery, Fujian Medical University Affiliated Longyan First Hospital, Longyan, PR China
| | - Yi-Xing Chen
- Department of Cardiology, Fujian Medical University Nanping First Hospital, Nanping, PR China
| | - Liang-Wan Chen
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, PR China; Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province, PR China.
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Reddy P, Nair KS, Kumar V, Bowen JM, Deyle DR, Pochettino A, Connolly HM, Anavekar NS. Thoracic Aortic Aneurysmal Disease: Comprehensive Recommendations for the Primary Care Physician. Mayo Clin Proc 2024; 99:111-123. [PMID: 38176819 DOI: 10.1016/j.mayocp.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 06/17/2023] [Accepted: 07/12/2023] [Indexed: 01/06/2024]
Abstract
Thoracic aortic aneurysm (TAA) is a commonly encountered disease that is defined as aortic dilation with an increase in diameter of at least 50% greater than the expected age- and sex-adjusted size. Thoracic aortic aneurysms are described by their size, location, morphology, and cause. Primary care clinicians and other noncardiologists are often the first point of contact for patients with TAA. This review is intended to provide them with basic information on the differential diagnosis, diagnostic evaluation, and medical and surgical management of TAAs. Management decisions depend on having as precise a diagnosis as possible. Fortunately, this can often be achieved with a stepwise diagnostic approach that incorporates imaging and targeted genetic testing. Our review includes recommendations. In this review, we discuss these issues at a basic level and include recommendations for patients considering pregnancy.
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Affiliation(s)
- Prajwal Reddy
- Department of Cardiology, Mayo Clinic, Rochester, MN.
| | - Kaavya S Nair
- College of Osteopathic Medicine, Kansas City University, Kansas City, MO
| | - Vinayak Kumar
- Department of Cardiology, Mayo Clinic, Rochester, MN
| | - Juan M Bowen
- Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - David R Deyle
- Department of Clinical Genomics, Mayo Clinic, Rochester, MN
| | | | | | - Nandan S Anavekar
- Department of Cardiology, Mayo Clinic, Rochester, MN; Department of Radiology, Mayo Clinic, Rochester, MN
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Carrel T, Sundt TM, von Kodolitsch Y, Czerny M. Acute aortic dissection. Lancet 2023; 401:773-788. [PMID: 36640801 DOI: 10.1016/s0140-6736(22)01970-5] [Citation(s) in RCA: 46] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 09/04/2022] [Accepted: 09/27/2022] [Indexed: 01/13/2023]
Abstract
Although substantial progress has been made in the prevention, diagnosis, and treatment of acute aortic dissection, it remains a complex cardiovascular event, with a high immediate mortality and substantial morbidity in individuals surviving the acute period. The past decade has allowed a leap forward in understanding the pathophysiology of this disease; the existing classifications have been challenged, and the scientific community moves towards a nomenclature that is likely to unify the current definitions according to morphology and function. The most important pathophysiological pathway, namely the location and extension of the initial intimal tear, which causes a disruption of the media layer of the aortic wall, together with the size of the affected aortic segments, determines whether the patient should undergo emergency surgery, an endovascular intervention, or receive optimal medical treatment. The scientific evidence for the management and follow-up of acute aortic dissection continues to evolve. This Seminar provides a clinically relevant overview of potential prevention, diagnosis, and management of acute aortic dissection, which is the most severe acute aortic syndrome.
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Affiliation(s)
- Thierry Carrel
- Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland.
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts' General Hospital, Harvard Medical School, Boston, MA, USA
| | - Yskert von Kodolitsch
- Department of Vascular Medicine, German Aortic Center, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Bad Krozingen, Germany; Faculty of Medicine, Albert Ludwig University Freiburg, Freiburg, Germany
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Choi BY, Kim JK, Cho JH. A Review of a Recent Meta-Analysis Study on Obstructive Sleep Apnea. JOURNAL OF RHINOLOGY 2022. [DOI: 10.18787/jr.2022.00422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
This paper summarizes a recent meta-analysis of various topics in obstructive sleep apnea (OSA). In addition to cardiovascular disease and neurocognitive dysfunction, a wide variety of diseases have been associated with OSA, and associations with cancer have also been reported. Although continuous positive airway pressure is a very effective treatment, the results have shown that it does not reduce the incidence of various complications. It has been reported that uvulopalatopharyngoplasty was effective, and robotic surgery for the tongue root and hypoglossal nerve stimulation were also effective. The effectiveness of various medications to reduce daytime sleepiness has also been demonstrated. Although exercise lowered the apnea-hypopnea index, it was not related to changes in body composition, and it was also reported that exercise combined with weight control were effective. Additionally, interesting and clinically meaningful meta-analysis results were summarized and presented.
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Paschou SA, Bletsa E, Saltiki K, Kazakou P, Kantreva K, Katsaounou P, Rovina N, Trakada G, Bakakos P, Vlachopoulos CV, Psaltopoulou T. Sleep Apnea and Cardiovascular Risk in Patients with Prediabetes and Type 2 Diabetes. Nutrients 2022; 14:nu14234989. [PMID: 36501019 PMCID: PMC9741445 DOI: 10.3390/nu14234989] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 11/19/2022] [Accepted: 11/21/2022] [Indexed: 11/25/2022] Open
Abstract
Obstructive sleep apnea (OSA) is a common but largely undiagnosed clinical condition, which is turning into a serious public health issue. Of note is that its prevalence is gradually increasing in parallel with the obesity and type 2 diabetes mellitus (T2DM) epidemics. The aim of this article is to comprehensively review the literature in order to evaluate the cardiovascular (CV) risk among patients with OSA and prediabetes or T2DM. OSA seems to be an independent risk factor for the development as well as the progression of T2DM, whereas it is associated with T2DM-related macrovascular and microvascular complications. OSA may also act as a potential risk factor for the presentation and development of CV disease, such as hypertension, coronary artery disease, heart failure, pulmonary hypertension, atrial fibrillation and other cardiac arrythmias, as well as stroke. OSA and T2DM also share common pathophysiological mechanisms leading to atherosclerosis. Considering that the coexistence of OSA and T2DM is an independent and cumulative risk factor for CV mortality, more so than the two diseases separately, clinicians and healthcare professionals should be aware of and screen for OSA in patients with T2DM. Notably, targeted therapy for both conditions seems to substantially improve CV prognosis.
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Affiliation(s)
- Stavroula A. Paschou
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece
- Correspondence:
| | - Evanthia Bletsa
- 3rd Department of Cardiology, Sotiria Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Katerina Saltiki
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Paraskevi Kazakou
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Kanella Kantreva
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Paraskevi Katsaounou
- 1st Department of Critical Care Medicine, Evangelismos Hospital, School of Medicine, National and Kapodistrian University of Athens, 10676 Athens, Greece
| | - Nikoletta Rovina
- 1st Department of Respiratory Medicine, Sotiria Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Georgia Trakada
- Respiratory Medicine Unit, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Petros Bakakos
- 1st Department of Respiratory Medicine, Sotiria Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Charalambos V. Vlachopoulos
- 1st Department of Cardiology, Hippokration Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Theodora Psaltopoulou
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece
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Luo B, Li Y, Zhu M, Cui J, Liu Y, Liu Y. Intermittent Hypoxia and Atherosclerosis: From Molecular Mechanisms to the Therapeutic Treatment. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:1438470. [PMID: 35965683 PMCID: PMC9365608 DOI: 10.1155/2022/1438470] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 07/12/2022] [Accepted: 07/20/2022] [Indexed: 12/24/2022]
Abstract
Intermittent hypoxia (IH) has a dual nature. On the one hand, chronic IH (CIH) is an important pathologic feature of obstructive sleep apnea (OSA) syndrome (OSAS), and many studies have confirmed that OSA-related CIH (OSA-CIH) has atherogenic effects involving complex and interacting mechanisms. Limited preventive and treatment methods are currently available for this condition. On the other hand, non-OSA-related IH has beneficial or detrimental effects on the body, depending on the degree, duration, and cyclic cycle of hypoxia. It includes two main states: intermittent hypoxia in a simulated plateau environment and intermittent hypoxia in a normobaric environment. In this paper, we compare the two types of IH and summarizes the pathologic mechanisms and research advances in the treatment of OSA-CIH-induced atherosclerosis (AS), to provide evidence for the systematic prevention and treatment of OSAS-related AS.
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Affiliation(s)
- Binyu Luo
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, Chinese Academy of Chinese Medical Sciences, Beijing 100091, China
| | - Yiwen Li
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, Chinese Academy of Chinese Medical Sciences, Beijing 100091, China
| | - Mengmeng Zhu
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, Chinese Academy of Chinese Medical Sciences, Beijing 100091, China
| | - Jing Cui
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, Chinese Academy of Chinese Medical Sciences, Beijing 100091, China
| | - Yanfei Liu
- The Second Department of Gerontology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China
| | - Yue Liu
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, Chinese Academy of Chinese Medical Sciences, Beijing 100091, China
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Gessler N, Wohlmuth P, Anwar O, Debus ES, Eickholt C, Gunawardene MA, Hakmi S, Heitmann K, Rybczynski M, Schueler H, Sheikhzadeh S, Tigges E, Wiest GH, Willems S, Adam E, von Kodolitsch Y. Sleep apnea predicts cardiovascular death in patients with Marfan syndrome: a cohort study. EPMA J 2022; 13:451-460. [PMID: 36061830 PMCID: PMC9437159 DOI: 10.1007/s13167-022-00291-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/20/2022] [Indexed: 11/30/2022]
Abstract
Background Surgical replacement of the aortic root is the only intervention that can prevent aortic dissection and cardiovascular death in Marfan syndrome (MFS). However, in some individuals, MFS also causes sleep apnea. If sleep apnea predicts cardiovascular death, a new target for predictive, preventive, and personalized medicine (PPPM) may emerge for those individuals with MFS who have sleep apnea. Methods This is an investigator-initiated study with long-term follow-up data of 105 individuals with MFS. All individuals were screened for sleep apnea regardless of symptoms. Cardiovascular death served as a primary endpoint, and aortic events as a secondary outcome. Results Sleep apnea with an apnea–hypopnea index (AHI) > 5/h was observed in 21.0% (22/105) with mild sleep apnea in 13% (14/105) and moderate to severe sleep apnea in 7.6% (8/105). After a median follow-up of 7.76 years (interquartile range: 6.84, 8.41), 10% (10/105) had died, with cardiovascular cause of death in 80% (8/10). After adjusting for age and body mass index (BMI), the AHI score emerged as an independent risk factor for cardiovascular death (hazard ratio 1.712, 95% confidence interval [1.061–2.761], p = 0.0276). The secondary outcome of aortic events occurred in 33% (35/105). There was no effect of the AHI score on aortic events after adjusting for age and BMI (hazard ratio 0.965, 95% confidence interval [0.617–1.509]), possibly due to a high number of patients with prior aortic surgery. Interpretation Sleep apnea is emerging as an independent predictor of cardiovascular death in MFS. It seems mandatory to screen all individuals with MFS for sleep apnea and to include these individuals, with both MFS and sleep apnea, in further studies to evaluate the impact of preventive measures with regard to cardiovascular death. Supplementary Information The online version contains supplementary material available at 10.1007/s13167-022-00291-4.
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Affiliation(s)
- Nele Gessler
- Department of Cardiology and Internal Intensive Care Medicine, Asklepios Clinic St. Georg, Semmelweis University, Campus Hamburg, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Luebeck, Berlin, Germany
- Asklepios Proresearch, Research Institute, Hamburg, Germany
| | - Peter Wohlmuth
- Asklepios Proresearch, Research Institute, Hamburg, Germany
| | - Omar Anwar
- Department of Cardiology and Internal Intensive Care Medicine, Asklepios Clinic St. Georg, Semmelweis University, Campus Hamburg, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Luebeck, Berlin, Germany
| | - Eike Sebastian Debus
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Luebeck, Berlin, Germany
- University Heart Center Hamburg Eppendorf, Hamburg, Germany
| | - Christian Eickholt
- Department of Cardiology and Internal Intensive Care Medicine, Asklepios Clinic St. Georg, Semmelweis University, Campus Hamburg, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Luebeck, Berlin, Germany
| | - Melanie A Gunawardene
- Department of Cardiology and Internal Intensive Care Medicine, Asklepios Clinic St. Georg, Semmelweis University, Campus Hamburg, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Luebeck, Berlin, Germany
| | - Samer Hakmi
- Department of Cardiology and Internal Intensive Care Medicine, Asklepios Clinic St. Georg, Semmelweis University, Campus Hamburg, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Luebeck, Berlin, Germany
| | - Kathrin Heitmann
- Department of Cardiology and Internal Intensive Care Medicine, Asklepios Clinic St. Georg, Semmelweis University, Campus Hamburg, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
- Asklepios Proresearch, Research Institute, Hamburg, Germany
| | - Meike Rybczynski
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Luebeck, Berlin, Germany
- University Heart Center Hamburg Eppendorf, Hamburg, Germany
| | - Helke Schueler
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Luebeck, Berlin, Germany
- University Heart Center Hamburg Eppendorf, Hamburg, Germany
| | - Sara Sheikhzadeh
- Emergency Department, Asklepios Clinic St. Georg, Semmelweis University, Campus Hamburg, Hamburg, Germany
- Emergency Department, Asklepios Clinic Harburg, Semmelweis University, Campus Hamburg, Hamburg, Germany
| | - Eike Tigges
- Department of Cardiology and Internal Intensive Care Medicine, Asklepios Clinic St. Georg, Semmelweis University, Campus Hamburg, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Luebeck, Berlin, Germany
| | - Gunther H Wiest
- Department of Pneumology and Sleep Medicine, Asklepios Clinic Harburg, Semmelweis University, Campus Hamburg, Hamburg, Germany
| | - Stephan Willems
- Department of Cardiology and Internal Intensive Care Medicine, Asklepios Clinic St. Georg, Semmelweis University, Campus Hamburg, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Luebeck, Berlin, Germany
| | - Ekaterina Adam
- University Heart Center Hamburg Eppendorf, Hamburg, Germany
| | - Yskert von Kodolitsch
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Luebeck, Berlin, Germany
- University Heart Center Hamburg Eppendorf, Hamburg, Germany
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Borsoi L, Armeni P, Donin G, Costa F, Ferini-Strambi L. The invisible costs of obstructive sleep apnea (OSA): Systematic review and cost-of-illness analysis. PLoS One 2022; 17:e0268677. [PMID: 35594257 PMCID: PMC9122203 DOI: 10.1371/journal.pone.0268677] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 05/03/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is a risk factor for several diseases and is correlated with other non-medical consequences that increase the disease's clinical and economic burden. However, OSA's impact is highly underestimated, also due to substantial diagnosis gaps. OBJECTIVE This study aims at assessing the economic burden of OSA in the adult population in Italy by performing a cost-of-illness analysis with a societal perspective. In particular, we aimed at estimating the magnitude of the burden caused by conditions for which OSA is a proven risk factor. METHODS A systematic literature review on systematic reviews and meta-analyses, integrated by expert opinion, was performed to identify all clinical and non-clinical conditions significantly influenced by OSA. Using the Population Attributable Fraction methodology, a portion of their prevalence and costs was attributed to OSA. The total economic burden of OSA for the society was estimated by summing the costs of each condition influenced by the disease, the costs due to OSA's diagnosis and treatment and the economic value of quality of life lost due to OSA's undertreatment. RESULTS Twenty-six clinical (e.g., diabetes) and non-clinical (e.g., car accidents) conditions were found to be significantly influenced by OSA, contributing to an economic burden ranging from €10.7 to €32.0 billion/year in Italy. The cost of impaired quality of life due to OSA undertreatment is between €2.8 and €9.0 billion/year. These costs are substantially higher than those currently borne to diagnose and treat OSA (€234 million/year). CONCLUSIONS This study demonstrates that the economic burden due to OSA is substantial, also due to low diagnosis and treatment rates. Providing reliable estimates of the economic impact of OSA at a societal level may increase awareness of the disease burden and help to guide evidence-based policies and prioritisation for healthcare, ultimately ensuring appropriate diagnostic and therapeutic pathways for patients.
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Affiliation(s)
- Ludovica Borsoi
- SDA Bocconi School of Management, Centre for Research on Health and Social Care Management (CERGAS), Milan, Italy
| | - Patrizio Armeni
- SDA Bocconi School of Management, Centre for Research on Health and Social Care Management (CERGAS), Milan, Italy
| | - Gleb Donin
- Department of Biomedical Technology, Czech Technical University in Prague, Kladno, Czech Republic
| | - Francesco Costa
- SDA Bocconi School of Management, Centre for Research on Health and Social Care Management (CERGAS), Milan, Italy
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Wang D, Xu JZ, Kang YY, Zhang W, Hu LX, Wang JG. Aortic Root Diameter in Hypertensive Patients With Various Stages of Obstructive Sleep Apnea. Am J Hypertens 2022; 35:142-148. [PMID: 34661652 PMCID: PMC8807158 DOI: 10.1093/ajh/hpab167] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 10/11/2021] [Accepted: 10/17/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is a risk factor of several cardiovascular diseases. We investigated the association between aortic root diameter and hypoxia-related parameters in hypertensive patients with OSA. METHODS Our study included 242 hypertensive patients with OSA (52 mild, 71 moderate, and 119 severe). All the patients underwent echocardiography for measuring aortic root diameter and polysomnography for measuring apnea–hypopnea index (AHI), oxygen desaturation index, and time spent with oxygen desaturation less than 90%. RESULTS The study patients included 19.8% women and had a mean (±SD) age of 49.9 ± 12.9 years, a mean aortic root diameter of 33.4 ± 2.6 mm, and a prevalence of echocardiographic aortic root dilation of 3.7%. Patients with mild, moderate, and severe OSA had similar echocardiographic left ventricular structure. However, patients with severe OSA had a significantly (P < 0.05) greater aortic root diameter (33.9 ± 2.4 mm vs. 32.4 ± 2.2 and 33.4 ± 2.9 mm, respectively) and higher prevalence of aortic root dilatation (5% vs. 1% and 3%, respectively) than those with mild and moderate OSA. Aortic root diameter corrected by body height was significantly (P < 0.001) associated with AHI, oxygen desaturation index and time spent with oxygen desaturation less than 90% (r = 0.23–0.33). After adjustment for various confounding factors, the associations between aortic root diameter and polysomnography parameters remained statistically significant (P < 0.05). CONCLUSIONS The severity of OSA was associated with the aortic root diameter. Patients with severe OSA had a greater aortic root diameter.
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Affiliation(s)
- Dian Wang
- The Shanghai Institute of Hypertension, Department of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jian-Zhong Xu
- The Shanghai Institute of Hypertension, Department of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yuan-Yuan Kang
- The Shanghai Institute of Hypertension, Department of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Wei Zhang
- The Shanghai Institute of Hypertension, Department of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lei-Xiao Hu
- The Shanghai Institute of Hypertension, Department of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ji-Guang Wang
- The Shanghai Institute of Hypertension, Department of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Neutrophil-to-Lymphocyte Ratio Facilitates Identification of Obstructive Sleep Apnea in Patients with Type B Aortic Dissection. Can Respir J 2021; 2021:8492468. [PMID: 34887971 PMCID: PMC8651425 DOI: 10.1155/2021/8492468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 11/07/2021] [Accepted: 11/17/2021] [Indexed: 11/18/2022] Open
Abstract
Purpose To determine whether the neutrophil-to-lymphocyte ratio (NLR) aids in the detection of obstructive sleep apnea (OSA) in patients with type B aortic dissection (TBAD). Methods 324 patients with TBAD or type B aortic intramural hematoma (TB-AIMH) underwent an overnight sleep study. We divided the eligible 256 studied subjects into three groups: group A (n = 109, TBAD patients with OSA), group B (n = 68, TB-AIMH patients with OSA), and group C (n = 79, TBAD patients without OSA). Baseline characteristics, biochemical and sleep parameters, and STOP-Bang questionnaire scores were collected. To assess the predictive efficacy of potential variables, multivariate logistic regression analysis and receiver operating characteristic (ROC) curves were used. Results The study found that about 58% of TBAD patients and 54% of TB-AIMH patients had OSA, a majority of whom had moderate to severe OSA (95.41% and 89.71%, respectively). In the comparison of sleep parameters between patients with TBAD and TB-AIMH, no other than apnea and hypopnea index (AHI) made a significant difference. The multivariate logistic regression analysis showed that neutrophil-to-lymphocyte ratio (NLR) (odds ratio (OR): 3.614, 95% confidence interval (CI): 2.273–5.748, and P < 0.05) and STOP-Bang scores (OR: 1.97, 95% CI: 1.34–2.90, and P < 0.05) were both independent predictors for OSA in patients with TBAD. ROC curves showed NLR had higher sensitivity (65% versus 59%) and specificity (86% versus 57%) for OSA than the STOP-Bang questionnaire. Furthermore, NLR was positively correlated with AHI through the Spearman test (r = 0.398 and P < 0.05). Conclusion NLR was an independent predictor of OSA in TBAD patients with higher sensitivity and specificity than the STOP-Bang questionnaire, and it was positively associated with AHI. NLR may aid in the diagnosis and risk stratification of OSA in TBAD patients.
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Zhang J, Zhang Z, Fu L, Wang L, Yang Y, Wang H, Zhou B, Wang W, Zhang J, Xin S. Obstructive Sleep Apnoea in Stanford Type B Aortic Dissection Is Associated With Multiple Imaging Signs Related to Late Aortic Events. Front Cardiovasc Med 2021; 8:752763. [PMID: 34869658 PMCID: PMC8636812 DOI: 10.3389/fcvm.2021.752763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/25/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Obstructive sleep apnoea (OSA) is highly prevalent in patients with Stanford type B aortic dissection (TBAD). Few studies have evaluated the effects of OSA on vascular changes in TBAD patients. This study aimed to explore the effect of OSA on aortic morphological changes in TBAD patients and its relation to late aortic events (LAEs). Methods: This case-control study included 143 TBAD patients. The diameters of different parts of the aorta were measured based on computed tomography angiography (CTA). According to the apnoea-hypopnoea index (AHI), OSA was classified as mild (5 ≤ AHI ≤ 15), moderate (15 < AHI ≤ 30), or severe (AHI > 30). The false lumen (FL) status was evaluated and classified as partially thrombosed, patent, or completely thrombosed. Results: The OSA prevalence in TBAD patients was 64.3%, and image differences related to LAEs between TBAD patients with and without OSA included the maximum aortic diameter at onset (37.3 ± 3.9 vs. 40.3 ± 4.5 mm, p < 0.001), the FL diameter of the proximal descending thoracic aorta (16.0 ± 6.8 vs. 20.3 ± 4.7 mm, p < 0.001), and the proportion of the FL that was partially thrombosed (39.2 vs. 64.1%, p = 0.004). Additionally, in the multivariable analysis of patients with OSA, the risks of an aortic diameter ≥40 mm, a proximal descending aorta FL ≥ 22 mm and a partially thrombosed FL were 4.611 (95% CI: 1.796–11.838, p = 0.001), 2.544 (95% CI: 1.050–6.165, p = 0.039), and 2.565 (95% CI: 1.167–5.637, p = 0.019), respectively, after adjustment for confounding factors. Trend tests showed that the risks of an aortic diameter ≥40 mm and a partially thrombosed FL increased with increasing OSA severity. Conclusions: TBAD patients with moderate to severe OSA have aortic dilatation in different parts of the aorta. OSA is an independent risk factor for multiple imaging signs related to LAEs, suggesting that OSA is an important factor affecting the prognosis of TBAD patients.
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Affiliation(s)
- Jiawei Zhang
- Department of Vascular Surgery, The First Hospital of China Medical University, Shenyang, China
| | - Zhe Zhang
- Department of Vascular Surgery, The First Hospital of China Medical University, Shenyang, China
| | - Lingyu Fu
- Department of Clinical Epidemiology and Evidence Medicine, The First Hospital of China Medical University, Shenyang, China
| | - Lei Wang
- Department of Vascular Surgery, The First Hospital of China Medical University, Shenyang, China
| | - Yu Yang
- Department of Vascular Surgery, The First Hospital of China Medical University, Shenyang, China
| | - Hao Wang
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Baosen Zhou
- Department of Clinical Epidemiology and Evidence Medicine, The First Hospital of China Medical University, Shenyang, China
| | - Wei Wang
- Department of Respiratory Medicine, The First Hospital of China Medical University, Shenyang, China
| | - Jian Zhang
- Department of Vascular Surgery, The First Hospital of China Medical University, Shenyang, China
| | - Shijie Xin
- Department of Vascular Surgery, The First Hospital of China Medical University, Shenyang, China
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Chen W, Li Y, Guo L, Zhang C, Tang S. An umbrella review of systematic reviews and meta-analyses of observational investigations of obstructive sleep apnea and health outcomes. Sleep Breath 2021; 26:167-188. [PMID: 33893906 PMCID: PMC8856999 DOI: 10.1007/s11325-021-02384-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 04/14/2021] [Accepted: 04/16/2021] [Indexed: 02/07/2023]
Abstract
Purpose The previous analysis of systematic reviews and meta-analyses have illustrated that obstructive sleep apnea (OSA) is correlated with multiple health outcomes. In the present research, our main aim was to execute an umbrella review to assess the available evidence for the associations between OSA and health outcomes. Methods Herein, a meta-analysis of previous observational investigations that have reported associations between OSA and health outcomes in all human populations and settings was performed. We used these studies to execute an umbrella review of available meta-analyses and systematic reviews. Results Sixty-six articles comprising 136 unique outcomes were enrolled in this analysis. Of the 136 unique outcomes, 111 unique outcomes had significant associations (p < 0.05). Only 7 outcomes (coronary revascularization after PCI, postoperative respiratory failure, steatosis, alaninetrans aminase (ALT) elevation, metabolic syndrome (MS), psoriasis, and Parkinson’s disease) had a high quality of evidence. Twenty-four outcomes had a moderate quality of evidence, and the remaining 80 outcomes had a weak quality of evidence. Sixty-nine outcomes exhibited significant heterogeneity. Twenty-five outcomes exhibited publication bias. Sixty-three (95%) studies showed critically low methodological quality. Conclusion Among the 66 meta-analyses exploring 136 unique outcomes, only 7 statistically significant outcomes were rated as high quality of evidence. OSA may correlate with an increased risk of coronary revascularization after PCI, postoperative respiratory failure, steatosis, ALT elevation, MS, psoriasis, and Parkinson’s disease.
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Affiliation(s)
- Weiwei Chen
- Department of Gastroenterology, The First Affiliated Hospital, Jinan University, Guangzhou, People's Republic of China
| | - Yuting Li
- Department of Gastroenterology, The First Affiliated Hospital, Jinan University, Guangzhou, People's Republic of China
| | - Liliangzi Guo
- Department of Gastroenterology, The First Affiliated Hospital, Jinan University, Guangzhou, People's Republic of China
| | - Chenxing Zhang
- Department of Gastroenterology, The First Affiliated Hospital, Jinan University, Guangzhou, People's Republic of China
| | - Shaohui Tang
- Department of Gastroenterology, The First Affiliated Hospital, Jinan University, Guangzhou, People's Republic of China.
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Castellana R, Aringhieri G, Gargani L, Maestri M, Schirru A, Bonanni E, Faraguna U. Effects of obstructive sleep apnea on the thoracic aorta and the main pulmonary artery: assessment by CT. J Clin Sleep Med 2021; 17:3-11. [PMID: 32876043 DOI: 10.5664/jcsm.8770] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
STUDY OBJECTIVES The influence of obstructive sleep apnea (OSA) on thoracic aortic size is debated. We aimed to identify possible relations between sleep parameters and the sizes of the ascending aorta (AA), the descending thoracic aorta (DTA), and the main pulmonary artery (MPA) in patients with untreated OSA and in a subgroup of participants without comorbidities capable of affecting the size of great thoracic vessels. METHODS We retrospectively measured AA, DTA, and MPA sizes on the chest computed tomography scans of 60 patients with OSA who underwent sleep studies within 1 year before or after the computed tomography. Univariate and multivariate analyses were performed on all patient findings, while an additional univariate analysis was conducted on the data for 22 participants without comorbidities. The latter had been divided into subgroups depending on the sleep parameters, and comparisons were made between them. RESULTS The logarithm of the time of oxygen saturation below 90% (CT90) significantly predicted AA and MPA sizes in all patients with OSA (P < .05). Oxygen desaturation index and minimum oxygen saturation were moderately correlated with AA and DTA sizes in patients without comorbidities (P < .01). In this group, subjects with oxygen desaturation index > 30 or minimum oxygen saturation < 81% had greater AA and DTA dimensions (P < .05). CONCLUSIONS In patients with OSA, time of oxygen saturation < 90% influenced AA and MPA sizes. In those patients without comorbidities, oxygen desaturation index and minimum oxygen saturation were moderately correlated with both AA and DTA sizes. Participants without comorbidities with oxygen desaturation index > 30 or minimum oxygen saturation < 81% had greater AA and DTA dimensions.
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Affiliation(s)
- Roberto Castellana
- Diagnostic and Interventional Radiology, University of Pisa, Pisa, Italy
| | - Giacomo Aringhieri
- Diagnostic and Interventional Radiology, University of Pisa, Pisa, Italy
| | - Luna Gargani
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Michelangelo Maestri
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa, Pisa, Italy
| | - Alessandro Schirru
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa, Pisa, Italy
| | - Enrica Bonanni
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa, Pisa, Italy
| | - Ugo Faraguna
- Department of Translational Research and of New Surgical and Medical Technologies, University of Pisa, Pisa, Italy.,Department of Developmental Neuroscience, IRCCS Fondazione Stella Maris, Pisa, Italy
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16
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Liu W, Zhang W, Wang T, Wu J, Zhong X, Gao K, Liu Y, He X, Zhou Y, Wang H, Zeng H. Obstructive sleep apnea syndrome promotes the progression of aortic dissection via a ROS- HIF-1α-MMPs associated pathway. Int J Biol Sci 2019; 15:2774-2782. [PMID: 31853217 PMCID: PMC6909961 DOI: 10.7150/ijbs.34888] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 08/20/2019] [Indexed: 01/25/2023] Open
Abstract
Aims: Obstructive sleep apnea syndrome (OSAS) has been increasingly recognized as an independent risk factor for aortic dissection (AD) and it is strongly associated with the extent of intermittent hypoxia and re-oxygenation (IH). This study aimed to clarify role of ROS- HIF-1α-MMPs pathway in the pathogenesis of AD and whether the HIF-1α inhibitor attenuates AD formation. Methods and results: 8-week-old male ApoE-/- mice were given β-aminopropionitrile at a concentration of 0.1 % for 3 weeks and infused via osmotic mini pumps with either saline or 2,500 ng/min/kg angiotensin II (Ang II) for 2 weeks. To mimic the OSAS, one group was exposed to IH, which consisted of alternating cycles of 20.9% O2/8% O2 FiO2 (30 episodes per hour) with 20 s at the nadir FiO2 during the 12-h light phase, 2 weeks before Ang II infusion. After Ang II infusion, we assessed remodeling in the aorta by echocardiography, histological and immunohistochemical analysis. IH treatment resulted in significant enlargement of the luminal area, destruction of the media, marked thickening of the adventitia, higher incidence of AD formation and lower survival rate in compared with the Ang II only group. Moreover, IH exposure markedly increased the aortic ROS production and subsequent HIF-1α expression, which in turn promoted the expressions of VEGF, MMP2 and MMP9 and finally leading to the progression of AD. Besides, in vitro study confirmed that IH induced HIF-1α expression plays an important role in the induction of MMPs and that is regulated by the PI3K/AKT/FRAP pathway. Intriguingly, a selective HIF-1α inhibitor KC7F2 could significantly ameliorate IH exposure induced aforementioned deleterious effects in vitro and in vivo.Conclusion: OSAS induced IH can promote the occurrence and progression of AD via a ROS- HIF-1α-MMPs associated pathway. The selective HIF-1α inhibitor KC7F2 could be a novel therapeutic agent for AD patient with OSAS.
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Affiliation(s)
- Wanjun Liu
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, PR China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, PR China
| | - Wenjun Zhang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, PR China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, PR China
| | - Tao Wang
- Department of Cardiology, Affiliated Hospital of Weifang Medical University, Weifang, Shandong, 261000, PR China
| | - Jinhua Wu
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, PR China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, PR China
| | - Xiaodan Zhong
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, PR China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, PR China
| | - Kun Gao
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, PR China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, PR China
| | - Yujian Liu
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, PR China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, PR China
| | - Xingwei He
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, PR China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, PR China
| | - Yiwu Zhou
- Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, PR China
| | - Hongjie Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, PR China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, PR China
- ✉ Corresponding author: Hongjie Wang, , Tel. +86-27-8369-3794, Fax: +86-27-8366-3186; Hesong Zeng, , Tel. +86-27-8369-2850, Fax: +86-27-8366-3186
| | - Hesong Zeng
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, PR China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, PR China
- ✉ Corresponding author: Hongjie Wang, , Tel. +86-27-8369-3794, Fax: +86-27-8366-3186; Hesong Zeng, , Tel. +86-27-8369-2850, Fax: +86-27-8366-3186
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