All-cause mortality in males with sleep apnoea syndrome: declining mortality rates with age

The Association between All-Cause Mortality and Obstructive Sleep Apnea in Adults: A U-Shaped Curve

Rationale: The relationship between sleep apnea (SA) and mortality remains a topic of debate. Objectives: We explored the relationship between the severity of SA and mortality and the effect of age on this association. Methods: Using a veterans' database, we extracted an apnea-hypopnea index (AHI) from physician interpretations of sleep studies by developing a natural language processing pipeline (with 944 manually annotated notes), which achieved more than 85% accuracy. We categorized the participants into no SA (n-SA; AHI, <5), mild to moderate SA (m-SA; 5 ⩽ AHI < 30), and severe SA (s-SA; AHI, ⩾30). We propensity-matched the m-SA and s-SA categories with n-SA on the basis of age, sex, race, ethnicity, body mass index, and 38 components of the Elixhauser Comorbidity Index. Using logistic regression, we estimated the odds ratio (OR) for all-cause mortality using m-SA as a reference. Also, we stratified the findings on the basis of age: young, ⩽40; middle aged, >40 and <65; and older, ⩾65 adults. Results: We extracted the AHI on 179,121 propensity-matched participants (mean age = 45.85 [SD = 14.1]; BMI = 30.15 ± 5.37 kg/m2; male, 79.09%; White, 64.5%). All-cause mortality rates among three AHI categories showed a U-shaped curve (11.55%, 7.07%, and 8.15% for n-SA, m-SA, and s-SA, respectively), regardless of age group. Compared with m-SA, the odds of all-cause mortality in n-SA (OR, 1.72; 95% confidence interval = 1.65-1.79) and s-SA (OR, 1.17; 95% confidence interval = 1.12-1.22) were higher. Stratifying by age yielded consistent findings. Conclusions: All-cause mortality showed a U-shaped association with the AHI. Further investigations to understand the underlying mechanisms of this phenomenon are warranted.

Exploring the Relationship Between Sleep Apnea, Myocardial Infarct Size, and Coronary Collaterals in Acute Myocardial Infarction: A Multidisciplinary Study

Purpose

We designed a study investigating the cardioprotective role of sleep apnea (SA) in patients with acute myocardial infarction (AMI), focusing on its association with infarct size and coronary collateral circulation.

Methods

We recruited adults with AMI, who underwent Level-III SA testing during hospitalization. Delayed-enhancement cardiac magnetic resonance (CMR) imaging was performed to quantify AMI size (percent-infarcted myocardium). Rentrop Score quantified coronary collateralization (scores 0-3, higher scores indicating augmented collaterals). Group differences in Rentrop grade and infarct size were compared using the Wilcoxon Rank-Sum test and Fisher's Exact test as appropriate, with a significance threshold set at p <0.05.

Results

Among 33 adults, mean age was 54.4±11.5 and mean BMI was 28.4±5.9. 8 patients (24%) had no SA, and 25 (76%) had SA (mild n=10, moderate n=8, severe n=7). 66% (n=22) underwent CMR, and all patients had Rentrop scores. Median infarct size in the no-SA group was 22% versus 28% in the SA group (p=0.79). While we did not find statistically significant differences, moderate SA had a trend toward a smaller infarct size (median 15.5%; IQR 9.23) compared to the other groups (no SA [22.0%; 16.8,31.8], mild SA [27%; 23.8,32.5], and severe SA [34%; 31.53], p=0.12). A higher proportion of moderate SA patients had a Rentrop grade >0, with a trend toward significance (moderate SA versus other groups: 62.5% versus 28%, p=0.08).

Conclusion

Our study did not find statistically significant differences in cardiac infarct size and the presence of coronary collaterals by sleep apnea severity among patients with AMI. However, our results are hypothesis-generating, and suggest that moderate SA may potentially offer cardioprotective benefits through enhanced coronary collaterals. These insights call for future research to explore the heterogeneity in ischemic preconditioning by SA severity and hypoxic burden to guide tailored clinical strategies for SA management in patients with AMI.

Age modifies the association between severe sleep apnea and all-cause mortality

PURPOSE

While sleep apnea (SA) gets more prevalent with advancing age, the impact of age on the association between SA and health outcomes is not well known. We assessed the association between the severity of SA and all-cause mortality in different age groups using large longitudinal data.

METHOD

We applied a Natural Language Processing pipeline to extract the apnea-hypopnea index (AHI) from the physicians' interpretation of sleep studies performed at the Veteran Health Administration (FY 1999-2022). We categorized the participants as no SA (n-SA, AHI< 5) and severe SA (s-SA, AHI≥30). We grouped the cohort based on age: Young≤40; Middle-aged:40-65; and Older adults≥65; and calculated the odds ratio (aOR) of mortality adjusted for age, sex, race, ethnicity, BMI, and Charlson-Comorbidity Index (CCI) using n-SA as the reference.

RESULTS

We identified 146,148 participants (age 52.23 ± 15.02; BMI 32.11 ± 6.05; male 86.7 %; White 66 %). Prevalence of s-SA increased with age. All-cause mortality was lower in s-SA compared to n-SA in the entire cohort (aOR,0.56; 95%CI: 0.54,0.58). Comparing s-SA to n-SA, the all-cause mortality rates (Young 1.86 % vs 1.49 %; Middle-aged 12.07 % vs 13.34 %; and Older adults 26.35 % vs 40.18 %) and the aOR diminished as the age increased (Young: 1.11, 95%CI: 0.93-1.32; Middle-aged: 0.64, 95%CI: 0.61-0.67; and Older adults: 0.44, 95%CI: 0.41-0.46).

CONCLUSION

The prevalence of severe SA increased while the odds of all-cause mortality compared to n-SA diminished with age. SA may exert less harmful effects on the aged population. A causality analysis is warranted to assess the relationship between SA, aging, and all-cause mortality.

My voyage in the enchanted world of sleep

In this paper, I describe my 45-year career in sleep research. I started my undergraduate studies at Tel Aviv University, where I was first introduced to the enchanted world of sleep, continued to my graduate studies with Wilse B. Webb at the University of Florida, and then to post-doctoral training with Dan Kripke at the University of California at San Diego. Then, I describe the evolution of my academic career at the Technion-Israel Institute of Technology, where I started in 1975 as an Assistant Professor and retired in 2019 as the President of the Institute. I describe the areas of research that I pursued and how the research developed, emphasizing unexpected results that guided me and my lab team in new directions. This includes my early studies on ultradian rhythms, inspired by Nathaniel Kleitman's Basic Rest Activity Cyle hypothesis, utilizing the ultrashort sleep-wake paradigm to chart the 24-hour sleep propensity function, and how these studies led us to explore the role of melatonin in sleep regulation. I also explain why we directed our attention to sleep apnea, and how clinical observations led to the provocative hypothesis that sleep apnea-typically seen as a disorder-may also play a protective role. Under the leadership of my research partner and wife, Lena, we confirmed this hypothesis. Also in this article, I describe my enthusiasm for the history of our field and, as derived from my experience as a Dean of Medicine and President of a university, I share my philosophy about the role of members of academia in society. I emphasize that none of my achievements could have been accomplished without the hard work and motivation of my students and research partners, who shared my enthusiasm and passion for the enchanted world of sleep. This paper is part of the Living Legends in Sleep Research series, which is sponsored by Idorsia Pharmaceuticals and Jazz Pharmaceuticals.

Association of obstructive sleep apnea with cardiometabolic diseases and cardiovascular mortality

BACKGROUND

Obstructive sleep apnea (OSA) is one of the leading respiratory disorders, increasing the risk of cardiometabolic diseases. In the study, we investigated the association between OSA and the risk of cardiometabolic diseases and all-cause and cardiovascular mortality in adults.

METHODS

Participants were enrolled in the National Health and Nutrition Examination Survey. The baseline covariates were compared between participants with and without OSA status. Multivariable logistic regression was performed to explore the association between OSA and cardiometabolic diseases, while Cox proportional regression was performed for all-cause and cardiovascular mortality.

RESULTS

OSA status was positively associated with higher risks of cardiometabolic diseases, including hypertension (odds ratio [OR] 1.28, 95% confidence interval [CI] 1.14-1.45; p < 0.001), diabetes (OR 1.46, 95% CI 1.22-1.76; p < 0.001), and cardiovascular diseases (OR 1.29, 95% CI 1.08-1.54; p = 0.006) after adjusting for numerous covariates. However, no associations of OSA with all-cause or cardiovascular mortality were observed.

CONCLUSION

OSA was associated with a higher risk of hypertension, diabetes, and cardiovascular diseases, but had no significant association with all-cause or cardiovascular mortality in adults.

A Scoping Review of Sleep Apnea: Where Do We Stand?

Obstructive sleep apnea (OSA), a condition in which there is a recurrent collapse of the upper airway while sleeping, is a widespread disease affecting 5% to 10% people worldwide. Despite several advances in the treatment modalities for OSA, morbidity and mortality remain a concern. Common symptoms include loud snoring, gasping for air during sleep, morning headache, insomnia, hypersomnia, attention deficits, and irritability. Obese individuals, male gender, older age (65+), family history, smoking, and alcohol consumption are well recognized risk factors of OSA. This condition holds the ability to increase inflammatory cytokines, cause metabolic dysfunction, and increase the sympathetic output, all of which exacerbate OSA due to their effect on the cardiovascular system. In this review, we discuss its brief history, risk factors, complications, treatment modalities, and the role of clinicians in curbing its risk.

Obesity and diabetes: the final frontier

INTRODUCTION

Obesity is a key target in the treatment and prevention of diabetes and independently to reduce the burden of cardiovascular disease. We reviewed the options now available and anticipated to deal with obesity.

AREAS COVERED

We considered the epidemiology, genetics, and causation of obesity and the relationship to diabetes, and the dietary, pharmaceutical, and surgical management of the condition. The literature search covered both popular media via Google Search and the academic literature as indexed on PubMed with search terms including obesity, childhood obesity, adipocytes, insulin resistance, mechanisms of satiety, bariatric surgery, GLP-1 receptor agonists, and SGLT2 inhibitors.

EXPERT OPINION

Although bariatric surgery has been the primary approach to treating obese individuals, the emergence of agents impacting the brain satiety centers now promises effective, non-invasive treatment of obesity for individuals with and without diabetes. The GLP-1 receptor agonists have assumed the primary role in treating obesity with significant weight loss. Long-term results with semaglutide and tirzepatide are now approaching the success seen with bariatric surgery. Future agents combining the benefits of satiety control and thermogenesis to dissipate caloric excess are under investigation.

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.

Relationship Between CPAP Termination and All-Cause Mortality: A French Nationwide Database Analysis

BACKGROUND

Randomized controlled trials have failed to demonstrate an effect of CPAP therapy on mortality. However, these studies have a number of important limitations, including low CPAP adherence, patient selection, and a small number of mortality events.

RESEARCH QUESTION

What are the effects of CPAP therapy termination in the first year on all-cause mortality in patients with OSA from the Nationwide Claims Data Lake for Sleep Apnea study?

STUDY DESIGN AND METHODS

Data from the Système National des Données de Santé (SNDS) database, the French national health insurance reimbursement system, for all new CPAP users ≥ 18 years of age were analyzed. The SNDS contains comprehensive, individualized, and anonymized data on health spending reimbursements for > 99% of all individuals living in France. OSA diagnosis was based on specific disease codes, whereas CPAP prescription was identified using specific treatment method codes. CPAP therapy termination was defined as the cessation of CPAP reimbursements triggered by the respiratory physician or sleep specialist in charge of follow-up. Patients who terminated therapy in the first year were propensity score matched with those who continued to use CPAP. The primary outcome was all-cause mortality. Three-year survival was visualized using Kaplan-Meier curves. Contributors to mortality also were determined.

RESULTS

Data from two matched groups each including 88,007 patients were included (mean age, 60 years; 64% men). Continuation of CPAP therapy was associated with a significantly lower risk of all-cause death compared with CPAP therapy termination (hazard ratio [HR], 0.61; 95% CI, 0.57-0.65; P < .01, log-rank test). Incident heart failure also was less common in patients who continued vs terminated CPAP therapy (HR, 0.77; 95% CI, 0.71-0.82; P < .01).

INTERPRETATION

These real-world data from a comprehensive, unbiased database highlight the potential for ongoing use of CPAP treatment to reduce all-cause mortality in patients with OSA.

Associations of the Severity of Obstructive Sleep Apnea With Age-Related Comorbidities: A Population-Based Study

Aging is accompanied by changes in the quantity and quality of sleep. Obstructive sleep apnea (OSA) is also more prevalent in the older population. Although severe OSA has been linked to a higher risk of cardiovascular disease regardless of adult age, clinical consequences of mild-to-moderate OSA in the older adults are still uncertain.

Objectives

To investigate the relationships between severity and metabolic, cognitive, and functional characteristics in community-dwelling older adults from a representative sample of the city of São Paulo.

Methods

In total, 199 participants of the first follow-up of the São Paulo Epidemiologic Sleep Study (EPISONO, São Paulo, Brazil) &gt;60 years were cross-sectionally assessed through questionnaires, physical evaluations, laboratory tests, and full in-lab polysomnography (PSG). Three groups according to the OSA severity were compared according to sociodemographic characteristics, anthropometric measures, PSG parameters, the frequency of comorbidities, and the use of medications.

Results

Participants' age ranged from 60 to 87 years with a mean of 70.02 ± 7.31, 59.8% female. In the univariate analysis, body mass index (BMI, kg/m2) (p = 0.049) and waist circumference (p = 0.005) were significantly higher in the participants with moderate OSA, but not among those with severe OSA. Participants with severe OSA had a higher arousal index (p = 0.007). Multivariate analysis showed that severe OSA was significantly associated with hypertension (p = 0.005), heart diseases (p = 0.025), and the use of two or more medications (p = 0.035).

Conclusion

In a population-based study, severe, but not mild-to-moderate, OSA in older adults was associated with hypertension and the use of more medications. As age advances, anthropometric indicators of obesity may not increase the risk of severe OSA.

[A long-term ischemic stroke risk score model in patients aged 60 years and older with obstructive sleep apnea: a multicenter prospective cohort study]

OBJECTIVE

To analyze the independent risk factors of long-term ischemic stroke and establish a nomogram for predicting the long-term risks in elderly patients with obstructive sleep apnea (OSA).

METHODS

This multicenter prospective cohort study was conducted from January, 2015 to October, 2017 among consecutive elderly patients (≥60 years) with newly diagnosed OSA without a history of cardio-cerebrovascular diseases and loss of important clinical indicators. The follow-up outcome was the occurrence of ischemic stroke. The baseline demographic and clinical data, sleep parameters, laboratory and ultrasound results were collected from all the patients, who were randomized into the modeling group (n=856) and validation group (n=258) at a 3∶1 ratio. LASSO regression was used for variable reduction and dimension screening, and the risk score prediction model of ischemic stroke was established based on Cox proportional hazard regression.

RESULTS

In the total of 1141 patients enrolled in this study, 58 (5.08%) patients experienced ischemic stroke during the median follow-up of 42 months (range 41-54 months). The cumulative incidence of ischemic stroke was 5.14% in the model group and 4.91% in the verification group (P < 0.05). Age (HR=3.44, 95% CI: 2.38- 7.77), fasting blood glucose (FPG) (HR=2.13, 95% CI: 1.22-3.72), internal diameter of the ascending aorta (HR=2.60, 95% CI: 1.0- 4.47), left atrial anteroposterior diameter (HR=1.98, 95% CI: 1.75-2.25) and minimum oxygen saturation (LSpO₂) (HR=1.57, 95% CI: 1.20-1.93) were identified as independent risk factors for ischemic stroke (P < 0.05 or 0.01). A long-term ischemic stroke risk score model was constructed based the regression coefficient ratios of these 5 risk variables. Before and after the application of the Bootstrap method, the AUC of the cohort risk score model was 0.84 (95% CI: 0.78- 0.90) and 0.85 (95% CI: 0.78- 0.89) in the model group and was 0.83 (95% CI: 0.73-0.93) and 0.82 (95%CI: 0.72-0.90) in the verification group, respectively, suggesting a good prediction efficiency and high robustness of the model. At the best clinical cutoff point, the cumulative incidence of ischemic stroke was significantly higher in the high-risk group than in the low-risk group (P=0.021).

CONCLUSION

This model can help to identify high-risk OSA patients for early interventions of the risks of ischemic stroke associated with OSA.

Patient-Defined Goals for Obstructive Sleep Apnea Treatment

Objectives

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

Study Design

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

Setting

Academic medical center and integrated managed care consortium.

Methods

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

Results

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

Conclusions

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

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 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.

Co-morbid insomnia and obstructive sleep apnoea is associated with all-cause mortality

STUDY OBJECTIVES

Increased mortality has been reported in people with insomnia and in those with obstructive sleep apnoea (OSA). However, these conditions commonly co-occur and the combined effect of co-morbid insomnia and sleep apnoea (COMISA) on mortality risk is unknown. This study used Sleep Heart Health Study (SHHS) data to assess associations between COMISA and all-cause mortality risk.

METHODS

Insomnia was defined as difficulties falling asleep, maintaining sleep, and/or early morning awakenings from sleep ≥16 times a month and daytime impairment. OSA was defined as an apnoea-hypopnoea index ≥15 events/h sleep. COMISA was defined if both conditions were present. Multivariable adjusted Cox proportional hazard models were used to determine the association between COMISA and all-cause mortality (n=1210) over 15 years of follow-up.

RESULTS

5236 participants were included. 2708 (52%) did not have insomnia/OSA (control), 170 (3%) had insomnia-alone, 2221 (42%) had OSA-alone, and 137 (3%) had COMISA. COMISA participants had a higher prevalence of hypertension (ORs [95%CI]; 2.00 [1.39, 2.90]) and cardiovascular disease compared to controls (1.70 [1.11, 2.61]). Insomnia-alone and OSA-alone were associated with higher risk of hypertension but not cardiovascular disease compared to controls. Compared to controls, COMISA was associated with a 47% (HR, 95% CI; 1.47 (1.06, 2.07)) increased risk of mortality. The association between COMISA and mortality was consistent across multiple definitions of OSA and insomnia.

CONCLUSIONS

Co-morbid insomnia and sleep apnoea was associated with higher rates of hypertension and cardiovascular disease at baseline, and an increased risk of all-cause mortality compared to no insomnia/OSA.

Polysomnographic Markers of Obstructive Sleep Apnea Severity and Cancer-Related Mortality: A Large Retrospective Multicenter Clinical Cohort Study

RATIONALE

The evidence for an association between cancer survival and obstructive sleep apnea (OSA) remains under-explored.

OBJECTIVES

To evaluate an association between markers of OSA severity (respiratory disturbances, hypoxemia, and sleep fragmentation) and cancer-related mortality in individuals with previously diagnosed cancer.

METHODS

We conducted a multicenter retrospective cohort study using linked clinical and provincial health administrative data on consecutive adults who underwent a diagnostic sleep study between 1994 and 2017 in four Canadian academic hospitals and were previously diagnosed with cancer through the Ontario Cancer Registry. Multivariable cause-specific Cox regressions were utilized to address the research objective.

RESULTS

We included 2,222 subjects. Over a median follow-up time of 5.6 years (IQR: 2.7-9.1), 261/2,222 (11.7%) individuals with prevalent cancer died from cancer-related causes, which accounted for 44.2% (261/590) of all-cause death. Controlling for age, sex, alcohol use disorder, prior heart failure, COPD, hypertension, diabetes, treatment for OSA, clinic site, year of the sleep study, and time since the cancer diagnosis, measures of hypoxemia and sleep fragmentation, but not apnea-hypopnea index were significantly associated with the cancer-specific mortality: % time spent with SaO2 <90% (HR per 5% increase: 1.05; 95% CI: 1.01-1.09); mean SaO2 (HR per 3% increase: 0.79; 0.68-0.92); and % of Stage 1 Sleep (HR per 16% increase: 1.27; 1.07-1.51).

CONCLUSION

In a large clinical cohort of adults with suspected OSA and previously diagnosed cancer, measures of nocturnal hypoxemia and sleep fragmentation as markers of OSA severity were significantly associated with cancer-related mortality, suggesting the need for more targeted risk awareness.

Association of nasal septal deviation with the incidence of anxiety, depression, and migraine: A national population-based study

Background & aims

Nasal obstruction caused by nasal septal deviation is very bothersome and, therefore, can affect the patient’s emotional state. However, little is known about the effect of nasal septal deviation (NSD) on the neuropsychiatric aspects of patients. Therefore, this study aims to verify the higher incidence of anxiety, depression, and migraine in patients diagnosed with NSD compared to general populations using big data.

Methods

This retrospective cohort study collected subjects from the Korean National Health Insurance Service (NHIS) database. Adjustments were made to minimize the confounding of variables for age, sex, residence type, income levels, hypertension, diabetes, dyslipidemia, rhinitis, and chronic rhinosinusitis between the two groups. The primary endpoint of this study was newly diagnosed anxiety, depression, and migraine between January 2009 and December 2018. Kaplan-Meier survival curves, logarithmic rank test, and Cox proportional regression test were used for statistical analysis.

Results

Among a total of 135,769 subjects in the NHIS database, 48,495 patients with NSD (NSD group) and 54,475 control subjects (control group) were selected. Patients with NSD had an increased risk of anxiety, depression, and migraine compared to the control group. In the NSD group, the adjusted hazard ratios (HR) were 1.236 (95% CI, 1.198–1.276) for anxiety, 1.289 (95% CI, 1.238–1.343) for depression, and 1.251 (95% CI, 1.214–1.290) for migraine.

Conclusion

NSD is associated with a higher incidence of anxiety, depression, and migraine. Therefore, it is suggested that physicians carefully consider psychoneurological distress and employ therapeutic strategies to minimize these conditions.

Impact of obstructive sleep apnea complicated with type 2 diabetes on long-term cardiovascular risks and all-cause mortality in elderly patients

BACKGROUND

The prognostic significance of obstructive sleep apnea (OSA) in elderly patients with type 2 diabetes is unclear. The aim of this study was to determine the risk of cardiovascular disease (CVD) and mortality in elderly patients with OSA complicated with type 2 diabetes compared to patients with OSA without type 2 diabetes.

METHODS

From January 2015 to October 2017, 1113 eligible elderly patients with OSA, no history of cardiovascular, ≥60 years of age, and complete follow-up records were enrolled in this consecutive multicentre prospective cohort study. All patients had completed polysomnography (PSG) examinations. An apnoea-hypopnoea index of ≥5 events per hour recorded by polysomnography was defined as the diagnostic criterion for OSA. We collected baseline demographics, clinical characteristics, sleep parameters and follow-up outcomes. The primary aim of this study was to identify the risk of incident major adverse cardiovascular events (MACE). Secondary outcomes were all-cause mortality, components of MACE and a composite of all events. Kaplan-Meier survival analysis and Cox proportional hazards models were used to evaluate whether type 2 diabetes was associated with incident events.

RESULTS

A total of 266 (23.9%) patients had OSA complicated with type 2 diabetes. MACE occurred in 97 patients during the median 42-month follow-up. Kaplan-Meier survival curves indicated a significant relationship between type 2 diabetes and MACE (log-rank P = 0.003). Multivariable Cox regression analysis showed that type 2 diabetes increased the risk of MACE (HR = 1.64, 95% CI:1.08-2.47, P = 0.019), hospitalisation for unstable angina (HR = 2.11, 95% CI:1.23-3.64, P = 0.007) and a composite of all events in elderly patients with OSA (HR = 1.70, 95% CI:1.17-2.49, P = 0.007). However, there were no significant differences in the incidence of cardiovascular death, all-cause mortality, MI and hospitalisation for heart failure between patients with and without diabetes (P > 0.05). The subgroup analysis demonstrated that females (AHR = 2.46, 95% CI:1.17-5.19, P = 0.018), ≥ 70 years (AHR = 1.95, 95% CI:1.08-3.52, P = 0.027), overweight and obese (AHR = 2.04, 95% CI:1.29-3.33, P = 0.002) with mild OSA (AHR = 2.42, 95% CI: 1.03-5.71, P = 0.044) were at a higher risk for MACE by diabetes.

CONCLUSION

OSA and type 2 diabetes are interrelated and synergistic with MACE, hospitalisation for unstable angina and a composite of all events development. Overweight and obese females, ≥ 70 years with mild OSA combined with type 2 diabetes presented a significantly high MACE risk.

Association of Obstructive Sleep Apnea with the Aging Process

Rationale: Evidence suggests that the physiopathologic consequences of obstructive sleep apnea (OSA) resemble those induced by aging. Some studies report that the deleterious effects associated with OSA might be age dependent. Objectives: To evaluate the association of OSA with the aging process and to determine whether this association is maintained across different age groups. Methods: This was an observational, prospective study including 599 patients with suspected OSA. Five hallmarks of aging were evaluated: alteration of cellular communication (serum CRP [C-reactive protein] concentration), deregulation of nutrient sensing (insulin resistance), telomere attrition (leukocyte telomeric length), mitochondrial dysfunction (leukocyte mitochondrial DNA copy number), and genomic instability (urinary 8-hydroxy-2-deoxyguanosine concentration). For age-stratified analyses, subjects were divided into four groups according to the apnea-hypopnea index (AHI) and the median age (50 yr): young patients without OSA (age < 50 yr old, AHI < 15 events/h), young patients with OSA (age < 50 yr old, AHI ⩾ 15 events/h), older patients without OSA (age ⩾ 50 yr old, AHI < 15 events/h), and older patients with OSA (age ⩾ 50 yr old, AHI ⩾ 15 events/h). Results: A dose-response relationship was found between the AHI, arousal index, and time during the night spent with an oxygen saturation less than 90% and the following hallmarks: alteration of cellular communication, deregulation of nutrient sensing, mitochondrial dysfunction, and genomic instability. Considering age-stratified analyses, OSA was associated with an increase in several hallmarks of aging in young patients, but no significant association of OSA was identified in older patients. Conclusions: In subjects under 50 years of age, OSA is associated with an increase in specific hallmarks of aging, independent of several known confounding factors.

Association Between Obstructive Sleep Apnea and Reduced Mortality in Critically Ill Patients: A Propensity Score-Based Analysis

Background

The impact of obstructive sleep apnea (OSA) on the prognosis of intensive care unit (ICU) patients remains controversial. Thus, this study aimed to determine the association between OSA status and outcomes in ICU patients.

Methods

We conducted a retrospective cohort study composed of 38,177 critically ill patients from the Medical Information Mart for Intensive Care III (MIMIC-III) database. Propensity score matching was used to evaluate the association between OSA and mortality in ICU adults.

Results

A total of 38,177 critically ill patients were included in this study. Among them, 1428 (3.71%) patients had OSA. Before matching, patients with OSA had a significantly lower 28-day mortality (relative risk (RR), 0.47; 95% confidence interval (CI), 0.38–0.58), 90-day mortality (RR, 0.50; 95% CI, 0.43–0.60), ICU mortality (RR, 0.41; 95% CI, 0.31–0.54), and in-hospital mortality (RR, 0.46; 95% CI, 0.36–0.57). After adjusting with propensity-score matching, the findings of reduced risk of mortality remained unchanged. The RR of 28-day mortality, 90-day mortality, ICU mortality, in-hospital mortality was 0.57 (95% CI, 0.34–0.57), 0.53 (95% CI, 0.40–0.70), 0.54 (95% CI, 0.37–0.79), and 0.55 (95% CI, 0.39–0.77), respectively.

Conclusion

This study indicated that ICU patients with OSA had a significantly lower risk of mortality compared with those without OSA.

Age and comorbidities are crucial predictors of mortality in severe obstructive sleep apnoea syndrome

BACKGROUND

Obstructive sleep apnoea syndrome (OSAS) is a highly prevalent disorder. The prognostic role of comorbidity in patients with OSAS and their role for risk stratification remain poorly defined.

METHODS

We studied 1,592 patients with severe OSAS diagnosed by polysomnography. The primary outcome was all-cause mortality. The standardized mortality ratio (SMR) was estimated as the ratio of observed deaths to expected number of deaths in the general population. The expected numbers of deaths were derived using mortality rates from the general Apulian population. The association of comorbidities with all-cause mortality was assessed using multivariable Cox regression analysis. Finally, recursive-partitioning analysis was applied to identify the combinations of comorbidities that were most influential for mortality and to cluster the patients into risk groups according to individual comorbidities RESULTS: During 11,721 person-years of follow-up, 390 deaths (3.33 deaths/100 person-years) occurred. The median follow-up was 7 (4-10) years. The SMR was 1.47 (95% confidence intervals 1.33-1.63). Age, sex, obesity, cardiovascular diseases (CVD), moderate-to-severe chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD) and malignancy were independently associated with mortality risk. Recursive-partitioning analysis allowed distinguishing three clinical phenotypes differentially associated with mortality risk. The combination of CKD with CVDs or with moderate-to-severe COPD conferred the highest risk.

CONCLUSIONS

Severe OSAS is associated with increased risk for all-cause death. Age and comorbidity are crucial predictors of mortality in patients with severe OSAS. Clustering patients according to comorbidities allows identifying clinically meaningful phenotypes.

Effect of Continuous Positive Airway Pressure on Arrhythmia in Atrial Fibrillation and Sleep Apnea: A Randomized Controlled Trial

RATIONALE

Sleep apnea (SA) is highly prevalent in patients with atrial fibrillation (AF), and both conditions are associated with adverse cardiovascular outcomes.

OBJECTIVES

To determine the effect of continuous positive airway pressure (CPAP) on AF burden.

METHODS

This open-label, parallel-group, randomized, controlled trial included patients with paroxysmal AF and moderate-to-severe SA (apnea-hypopnea index ≥15). Eligible patients were randomized (1:1) to 5 months' treatment with CPAP plus usual care (CPAP, n=55) or usual care alone (control, n=54) by a computerised system. Outcome assessment was blinded. The planned primary outcome was the difference between CPAP treatment and control in change of AF burden (% of time in AF), as measured by implantable loop recorder.

MEASUREMENTS AND MAIN RESULTS

A total of 579 patients with paroxysmal AF had respiratory polygraphy, of whom 244 (42.1%) had moderate-to-severe SA. Of these, 158 (64.8%) participated in the CPAP run-in period, of whom 40 (25.3%) patients did not tolerate the treatment. One-hundred-eight patients were available for the primary analysis. The mean time in AF decreased from 5.6% at baseline to 4.1% during the last three months of CPAP intervention and from 5.0% to 4.3% in the control group. The adjusted between-group difference at follow-up was -0.63 (95% confidence interval: -2.55 to 1.30) percentage points; P=0.52. Seven serious adverse events (13%) occurred in the CPAP group, and two (4%) occurred in the control group.

CONCLUSIONS

In patients with paroxysmal AF and SA, treatment with CPAP did not result in a statistically significant reduction in the burden of AF. Clinical trial registration available at www.clinicaltrials.gov, ID: NCT02727192.

Shifting and reducing breathing disturbance in patients with very severe obstructive sleep apnea by modified Z-palatoplasty with one-layer closure in one-stage multilevel surgery

Very severe obstructive sleep apnea (OSA) with apnea-hypopnea index (AHI) ≥ 60 events/h differs in several areas from OSA with other severities, including having a low-level daytime partial pressure of oxygen and residual on-CPAP (continuous positive airway pressure) AHIs greater than 20/h. Patients with very severe OSA show narrow retroglossal space and confined framework, which is difficult to be enlarged via conventional Uvulopalatopharyngoplasty (UPPP) surgery, resulting in poor response to non-framework surgeries. Our latest report showed efficacy and efficiency for subjects undergoing modified Z-palatoplasty (ZPP) with one-layer closure in a one-stage multilevel surgery. It is unclear whether and how this procedure could help patients with very severe OSA characterized with confined framework. From Mar. 2015 to May 2018, we enrolled 12 patients with very severe OSA receiving one-stage multi-level surgery with modified ZPP with one-layer closure, CO2 laser partial tongue-base glossectomy, and bilateral septomeatoplasty. Our results show that the surgery reduced AHI from 73.8 ± 10.7 to 30.8 ± 23.2 events/h and achieved a mean AHI reduction of 58.3% (p < 0.001 against 0 reduction or no surgery). The surgery shifted components of the breathing disturbances. It reduced more apnea than hypopnea and might convert some apnea to hypopnea.

Recognizable Clinical Subtypes of Obstructive Sleep Apnea After Ischemic Stroke: A Cluster Analysis

BACKGROUND AND PURPOSE

Obstructive sleep apnea (OSA) increases risk of stroke recurrence and mortality in ischemic stroke patients. However, equivocal treatment effects warrant further categorization of post-stroke OSA for risk stratification and individualized treatment planning.

METHODS

The study recruited 232 ischemic stroke patients with moderate-to-severe OSA admitted for inpatient rehabilitation consecutively. Latent class analysis was performed based on sex, age, smoking, daytime sleepiness, depression, obesity, sedative use, atrial fibrillation, diabetes, dyslipidemia, hypertension, recurrent stroke and dysphagia. The augmentation index, a marker of arterial stiffness, was measured by applanation tonometry.

RESULTS

A three-cluster model provided the best fit. Cluster 1 (n=84, 36.2%) was older in age, predominantly female, with the highest hypopnea index and prevalence of atrial fibrillation. Moreover, patients in Cluster 1 had significantly higher augmentation index than those in Cluster 2. Cluster 2 patients (N=80, 34.5%) were of older age, predominantly male, with the highest prevalence of depression, the lowest prevalence of hypertension and had the most normal body mass index (BMI). Additionally, Cluster 2 had less nocturnal hypoxia as compared to Cluster 3. Cluster 3 (n=68, 29.3%) was the youngest in age, predominantly male, with the highest BMI, cumulative risk score, and prevalence of dyslipidemia of the three clusters.

CONCLUSION

Post-stroke OSA can be categorized into three clinical phenotypes. Patients in Clusters 1 and 3 both had elevated cardiovascular risk and treatment can be based on their distinct characteristics. Patients in Cluster 2 had relatively lower risk of cardiovascular events and the benefits of OSA treatment requires further study.

Comparison of clinical and polysomnographic characteristics in young and old patients with obstructive sleep apnea syndrome

AIM

This study aimed to determine the differences in the clinical, demographic and polysomnographic characteristics of OSAS between patients older than and younger than 65 years of age.

METHODS

Two groups of OSAS patients under 65 years of age and older who underwent PAP treatment in our sleep center were included in the study. Demographic, clinical, and polysomnographic variables of patients were compared as well as the PAP device usage compliance.

RESULTS

The study was conducted with 183 patients (81 females and 102 males) having the diagnosis of OSAS. The ages of the patients ranged from 37 to 85 years (mean: 58.77 ± 12.59). The incidence of apnea, chest pain, arrhythmia, headache, non-concentration, forgetfulness, psychiatric disorders, motor activity, enuresis, libido and impotence complaints as well as the sedative usage rates and incidence of additional diseases were higher in elderly patients. Apnea hypopnea index, inspiratory positive airway pressure, and expiratory positive airway pressure measurements were significantly higher in the elderly group. The rates of NREM2 (%) and NREM3 (%) were lower in elderly patients.

CONCLUSION

Many comorbid medical conditions, concomitant drug use, and age-related physiological changes in sleep architecture and circadian rhythm and their effects on sleep should be considered in the elderly sleep.

A Non-Framework Multilevel Surgery May Reduce Mean Heart Rate in Patients with Very Severe Obstructive Apnea Having Confined Retroglossal Space and Framework

An elevated mean heart rate in untreated patients of obstructive sleep apnea (OSA) may lead to a higher risk of mortality and the development of various cardiovascular diseases. The elevation may positively relate to the severity of OSA and present in both wakefulness and sleep. A reduction in heart rate has been presented in reports of treating OSA patients with continuous positive airway pressure (CPAP). However, patients with very severe OSA may refuse use of CPAP devices and advocated surgeries, such as direct skeletal surgery or tracheostomy. It is unclear whether the non-framework multilevel surgery we reported previously can overcome the unfavorable anatomy and reduce mean heart rate, which serves as a risk factor of mortality. Here, we show that multilevel surgery reduced the mean heart rate from 68.6 to 62.7 with a mean reduction of 5.9 beats/min. The results suggest that the surgery may reduce the risk of consequences and mortality associated with an elevated mean heart rate, such as various cardiovascular diseases. We disclose these findings, along with the variations and possible risks to our future patients with very severe OSA who refuse or cannot use a CPAP device or reject direct skeletal surgery.

Rhythm Control in Heart Failure Patients with Atrial Fibrillation

AF and heart failure (HF) commonly coexist. Left atrial ablation is an effective treatment to maintain sinus rhythm (SR) in patients with AF. Recent evidence suggests that the use of ablation for AF in patients with HF is associated with an improved left ventricular ejection fraction and lower death and HF hospitalisation rates. We performed a systematic search of world literature to analyse the association in more detail and to assess the utility of AF ablation as a non-pharmacological tool in the treatment of patients with concomitant HF.

Increasing Hypopnea in Sleep Breathing Disturbance Improves Postoperative Oxygen Saturation in Patients with Very Severe Obstructive Sleep Apnea

In patients of very severe obstructive sleep apnea (OSA) with confined framework, reducing volume is difficult to achieve a postoperative apnea-hypopnea index (AHI) qualifying the classical surgical success. However, a higher AHI with a larger part of hypopneas may have similar or even less severity of oxygen (O2) desaturation, compared to a lower index mostly made of apneas. Here, in 27 consecutive enrolled patients, we show that besides the improvement of mean AHI, the multilevel surgery increased hypopnea in AHI from 29.1% to 77.3%, and improves postoperative O2 saturation by reducing desaturation frequency (mean desaturation index decreased from 62.5 to 24.4 events/h) and level (mean oxyhemoglobin saturation of pulse oximetry (SpO2) desaturation cut down from 10.0 to 5.8%). The mean SpO2 improved from 92.3% to 94.7%, and the improvement was positively related to the proportion increase of hypopnea/AHI. The results suggest that the non-framework surgery could help patients with very severe OSA whose AHIs are ≥60 events/h in terms of improving postoperative O2 saturation. Due to the improvement also presented in those not qualified as classical surgical success, further studies are needed to clarify the connection between O2 desaturation and various consequences to reconsider defining a surgical success.

The Impact of Telehealth on the Organization of the Health System and Integrated Care

Sleep medicine is a rapidly developing field of medicine that is well-suited to initiatives such as Telehealth to provide safe, effective clinical care to an expanding group of patients. The increasing prevalence of sleep disorders has resulted in long waiting lists and lack of specialist availability. Telemedicine has potential to facilitate a move toward an integrated care model, which involves professionals from different disciplines and different organizations working together in a team-oriented way toward a shared goal of delivering all of a person's care requirements. Issues around consumer health technology and nonphysician sleep providers are discussed further in the article.

Effect of continuous positive airway pressure on inflammatory, antioxidant, and depression biomarkers in women with obstructive sleep apnea: a randomized controlled trial

STUDY OBJECTIVES

The effect of continuous positive airway pressure (CPAP) on mediators of cardiovascular disease and depression in women with obstructive sleep apnea (OSA) is unknown. We aimed to assess the effect of CPAP therapy on a variety of biomarkers of inflammation, antioxidant activity, and depression in women with OSA.

METHODS

We conducted a multicenter, randomized controlled trial in 247 women diagnosed with moderate-to-severe OSA (apnea-hypopnea index [AHI] ≥ 15). Women were randomized to CPAP (n = 120) or conservative treatment (n = 127) for 12 weeks. Changes in tumor necrosis factor α (TNFα), interleukin 6 (IL-6), C-reactive protein (CRP), intercellular adhesion molecule 1 (ICAM-1), catalase (CAT), superoxide dismutase (SOD), and brain-derived neurotrophic factor (BDNF) were assessed. Additional analyses were conducted in subgroups of clinical interest.

RESULTS

Women had a median (25th-75th percentiles) age of 58 (51-65) years, body mass index 33.5 (29.0-38.3) kg/m2, and AHI 33.3 (22.8-49.3). No differences were found between groups in the baseline levels of the biomarkers. After 12 weeks of follow-up, there were no changes between groups in any of the biomarkers assessed. These results did not change when the analyses were restricted to sleepy women or to those with severe OSA. In women with CPAP use at least 5 hours per night, only TNFα levels decreased compared to the control group (-0.29 ± 1.1 vs -0.06 ± 0.53, intergroup difference -0.23 [95% CI = -0.03 to -0.50]; p = 0.043).

CONCLUSIONS

Twelve weeks of CPAP therapy does not improve biomarkers of inflammation, antioxidant activity, or depression compared to conservative treatment in women with moderate-to-severe OSA.

TRIAL REGISTRATION

NCT02047071.

Effect of ventilation therapy on mortality rate among obesity hypoventilation syndrome and obstructive sleep apnoea patients

INTRODUCTION

The prevalence of obesity is continually increasing worldwide, which increases the incidence of obesity hypoventilation syndrome (OHS) and its consequent mortality.

METHODS

We reviewed the therapy mode, comorbidity and mortality of all OHS patients treated at our hospital between 2005 and 2016. The control group consisted of randomly selected patients with obstructive sleep apnoea (OSA) treated during the same period.

RESULTS

We studied 206 OHS patients and 236 OSA patients. The OHS patients were older (56.3 versus 52.3 years, p<0.001) and heavier (body mass index 46.1 versus 32.2 kg·m-2, p<0.001), and the percentage of women was higher (41.2% versus 24.2%, p<0.001), respectively. The OHS patients had more hypertension (83% versus 61%, p<0.001) and diabetes (62% versus 31%, p<0.001) than the OSA patients, but no higher stroke (4% versus 8%, p=0.058) or ischaemic heart disease (14% versus 15%, p=0.437) incidence. The 5- and 10-year, unadjusted survival rates were lower among the OHS patients than among the OSA patients (83% versus 96% and 74% versus 91%, respectively; p<0.001). Differences in mortality rates were not related to age, sex or body mass index; covariates such as Charlson Comorbidity Index and ventilation therapy predicted survival. The mortality rate decreased significantly (p<0.001) both in OHS and OSA patients even after adjusting for covariates.

CONCLUSIONS

The mortality rate in OHS was significantly higher than that in OSA patients even after adjusting for covariates. Ventilation therapy by continuous positive airway pressure or noninvasive ventilation have reduced mortality significantly in all patients.

Apnea-Hypopnea Event Duration Predicts Mortality in Men and Women in the Sleep Heart Health Study

RATIONALE

Obstructive sleep apnea is a risk factor for mortality, but its diagnostic metric-the apnea-hypopnea index-is a poor risk predictor. The apnea-hypopnea index does not capture the range of physiological variability within and between patients, such as degree of hypoxemia and sleep fragmentation, that reflect differences in pathophysiological contributions of airway collapsibility, chemoreceptive negative feedback loop gain, and arousal threshold.

OBJECTIVES

To test whether respiratory event duration, a heritable sleep apnea trait reflective of arousal threshold, predicts all-cause mortality.

METHODS

Mortality risk as a function of event duration was estimated by Cox proportional hazards in the Sleep Heart Health Study, a prospective community-based cohort. Gender-specific hazard ratios were also calculated.

MEASUREMENTS AND MAIN RESULTS

Among 5,712 participants, 1,290 deaths occurred over 11 years of follow-up. After adjusting for demographic factors (mean age, 63 yr; 52% female), apnea-hypopnea index (mean, 13.8; SD, 15.0), smoking, and prevalent cardiometabolic disease, individuals with the shortest-duration events had a significant hazard ratio for all-cause mortality of 1.31 (95% confidence interval, 1.11-1.54). This relationship was observed in both men and women and was strongest in those with moderate sleep apnea (hazard ratio, 1.59; 95% confidence interval, 1.11-2.28).

CONCLUSIONS

Short respiratory event duration, a marker for low arousal threshold, predicts mortality in men and women. Individuals with shorter respiratory events may be predisposed to increased ventilatory instability and/or have augmented autonomic nervous system responses that increase the likelihood of adverse health outcomes, underscoring the importance of assessing physiological variation in obstructive sleep apnea.

Cardiovascular Effect and Symptom Profile of Obstructive Sleep Apnea: Does Sex Matter?

STUDY OBJECTIVES

To evaluate the influence of sex on obstructive sleep apnea (OSA)-related symptoms and prevalent cardiovascular disease (CVD) in a large clinical population of patients.

METHODS

A total of 6,716 patients (mean age 52 years, 24% women) had undergone diagnostic polysomnography and completed the Epworth Sleepiness Scale (ESS), Athens Insomnia Scale, and Beck Depression Inventory. We investigated the predictive value of sex on associated symptoms and prevalent cardiovascular disease, after adjustment for relevant confounding factors including age, obesity, and comorbidities.

RESULTS

Most of the patients (90%) had OSA (apnea-hypopnea index [AHI] ≥ 5 events/h), and 66% were obese. Women were older than men and had a higher body mass index; however, men had a thicker neck circumference, a higher waist-to-hip ratio, and increased OSA severity (AHI 36 versus 27 events/h, P < .001). Female sex independently predicted prevalent CVD after adjustment for confounders (odds ratio [95% CI] 1.476 [1.154-1.887], P = .002). Men independently were more likely to report driving problems (3.359 [2.470-4.569], P < .001) and excessive daytime sleepiness (ESS ≥ 16) (1.355 [1.036-1.773], P = .027). Furthermore, female sex was an independent predictive factor for depressive symptoms (2.473 [1.831-3.340], P < .001), frequent awakenings (1.703 [1.323-2.192], P < .001), nocturia (1.727 [1.340-2.226], P < .001) and morning headaches (1.855 [1.488-2.326], P < .001).

CONCLUSIONS

Females referred for sleep studies were more likely to exhibit CVD and less likely to complain of typical OSA symptoms than males in this large clinical patient cohort.

A meta-analysis of continuous positive airway pressure therapy in prevention of cardiovascular events in patients with obstructive sleep apnoea

Aims

To assess whether continuous positive airway pressure (CPAP) therapy reduces major adverse cardiovascular events (MACE) in patients with moderate-to-severe obstructive sleep apnoea (OSA).

Methods and results

A total of 235 articles were recovered using MEDLINE, EMBASE and Cochrane library (inception-December 2016) and references contained in the identified articles. Seven randomized controlled trials (RCTs) were selected for final analysis. Analysis of 4268 patients demonstrated non-significant 26% relative risk reduction in MACE with CPAP [risk ratio (RR) 0.74; 95% confidence interval (CI) 0.47-1.17; P = 0.19, I2 = 48%]. A series of sensitivity analyses suggested that increased CPAP usage time yielded significant risk reduction in MACE. and stroke. Subgroup analysis revealed that CPAP adherence time ≥4 hours (h)/night reduced the risk of MACE by 57% (RR 0.43; 95% CI 0.23-0.80; P = 0.01, I2 = 0%). CPAP therapy showed no beneficial effect on myocardial infarction (MI), all-cause mortality, atrial fibrillation/flutter (AF), or heart failure (HF) (P > 0.05). CPAP had positive effect on mood and reduced the daytime sleepiness [Epworth Sleepiness Scale (ESS): mean difference (MD) -2.50, 95% CI - 3.62, -1.39; P < 0.001, I2 = 81%].

Conclusion

CPAP therapy might reduce MACE and stroke among subjects with CPAP time exceeding 4 h/night. Additional randomized trials mandating adequate CPAP time adherence are required to confirm this impression.

The impact of obstructive sleep apnea and PAP therapy on all-cause and cardiovascular mortality based on age and gender - a literature review

BACKGROUND

Obstructive sleep apnea (OSA) is a common sleep disorder which negatively impacts different body systems, especially the cardiovascular system. The correlation between sleep related breathing disorders and cardiovascular diseases has been well studied. However, the impact of OSA on cardiovascular related mortality and the role of positive airway pressure therapy in decreasing mortality is unclear. We reviewed studies investigating the impact of OSA on all-cause and cardiovascular related mortality in both genders, and in different age groups.

METHODS

A literature search (PubMed) using two phrases "obstructive sleep apnea and co-morbidities in males and females" and "obstructive sleep apnea and co-morbidities by age" yielded a total of 214 articles. Nineteen articles met the inclusion criteria.

RESULTS

The studies reviewed showed conflicting results. Some showed that OSA increases all cause and cardiovascular related mortality predominantly in the middle-aged group (40-65) followed by a plateau or a reduction in mortality. Other studies showed a positive linear correlation between OSA and mortality up to the age of 80. The same controversy was noted for gender; some studies did not observe an increase in mortality in females with OSA, while others observed a trend for an increase in mortality in females.

CONCLUSION

There is a debate in the literature regarding the impact of OSA on all-cause and cardiovascular mortality in both genders and in different age groups. However, the variation in results might be related to different study designs and significant epidemiological prevalence of OSA in males and females.

Long term management of obstructive sleep apnea and its comorbidities

Obstructive sleep apnea (OSA) is a worldwide highly prevalent disease associated with systemic consequences, including excessive sleepiness, impairment of neurocognitive function and daytime performance, including driving ability. The long-term sequelae of OSA include and increase risk for cardiovascular, cerebrovascular and metabolic syndrome disorders that ultimately lead to premature death if untreated. To ensure optimal long-term outcomes, the assessment and management of OSA should be personalized with the involvement of the appropriate specialist. Most studies have demonstrated inmediate improvement in daytime somnolence and quality of life with CPAP and other therapies, but the effect of long-term treatment on mortality is still under debate. Currently, the long-term management of OSA should be based on a) identifying physiological or structural abnormalities that are treatable at the time of patient evaluation and b) comprehensive lifestyle interventions, especially weight-loss interventions, which are associated with improvements in OSA severity, cardiometabolic comorbidities, and quality of life. In long-term management, attention should be paid to the clinical changes related to a potential reoccurrence of OSA symptoms and it is also necessary to monitor throughout the follow up how the main associated comorbidities evolve.

Effect of age on the cardiovascular remodelling induced by chronic intermittent hypoxia as a murine model of sleep apnoea

BACKGROUND AND OBJECTIVE

Chronic intermittent hypoxia (CIH) is a major determinant of the cardiovascular morbidity associated with obstructive sleep apnoea (OSA), and the magnitude of CIH impact may be influenced by ageing. Here, we assessed the role of ageing in the early cardiovascular structural remodelling induced by severe CIH in a murine model of OSA.

METHODS

Cardiovascular remodelling was assessed in young (2 months old, n = 20) and aged (18 months old, n = 20) C57BL/6 female mice exposed to CIH (20% O₂ for 40 s, 5% O₂ for 20 s) or normoxia (room air) for 8 weeks (6 h/day).

RESULTS

Early vascular remodelling was observed in young mice exposed to CIH as illustrated by intima-media thickening (mean change: 4.6 ± 2.6 μm; P = 0.02), elastin fibre disorganization (mean change: 9.2 ± 4.5%; P = 0.02) and fragmentation (mean change: 2.5 ± 0.8%; P = 0.03), and collagen (mean change: 3.2 ± 0.6%; P = 0.001) and mucopolysaccharide accumulation (mean change: 2.4 ± 0.8%; P = 0.01). In contrast, vascular remodelling was not apparent in aged mice exposed to CIH. Furthermore, left ventricular perivascular fibrosis (mean change: 0.71 ± 0.1; P < 0.001) and hypertrophy (mean change: 0.17 ± 0.1; P = 0.038) were increased by CIH exposure in young mice, but not in aged mice. Principal component analysis identified similar cardiovascular alterations among the young mice exposed to CIH and both older mouse groups, suggesting that CIH induces premature cardiovascular senescence.

CONCLUSION

Cardiovascular remodelling induced by severe CIH is affected by the age at which CIH onset occurs, suggesting that the deleterious cardiovascular effects associated with CIH may be more pronounced in younger populations, and such changes resemble chronological age-related declines in cardiovascular structural integrity.

The Relationship between Obstructive Sleep Apnea and Alzheimer's Disease

Obstructive sleep apnea (OSA) and Alzheimer's disease (AD) are highly prevalent conditions with growing impact on our aging society. While the causes of OSA are now better characterized, the mechanisms underlying AD are still largely unknown, challenging the development of effective treatments. Cognitive impairment, especially affecting attention and executive functions, is a recognized clinical consequence of OSA. A deeper contribution of OSA to AD pathogenesis is now gaining support from several lines of research. OSA is intrinsically associated with disruptions of sleep architecture, intermittent hypoxia and oxidative stress, intrathoracic and hemodynamic changes as well as cardiovascular comorbidities. All of these could increase the risk for AD, rendering OSA as a potential modifiable target for AD prevention. Evidence supporting the relevance of each of these mechanisms for AD risk, as well as a possible effect of AD in OSA expression, will be explored in this review.

Domiciliary use of transcutaneous electrical stimulation for patients with obstructive sleep apnoea: a conceptual framework for the TESLA home programme

Obstructive sleep apnoea (OSA) is a global health problem of increasing prevalence. Effective treatments are available with continuous positive airway pressure (CPAP) therapy and mandibular advancement devices (MAD). However, there is limited long-term adherence to therapy, as CPAP and MAD require permanent usage to avoid recurrence of the symptoms and adverse ill health. Alternative treatments would aid in the treatment cascade to manage OSA effectively whenever standard therapy has been trialled and failed. Hypoglossal nerve stimulation (HNS), an invasive approach to stimulate the pharyngeal dilator muscles of the upper airway during sleep, has been approved for the treatment of OSA by several healthcare systems in recent years. In parallel to the development of HNS, a non-invasive approach has been developed to deliver electrical stimulation. Transcutaneous electrical stimulation in obstructive sleep apnoea (TESLA) uses non-invasive electrical stimulation to increase neuromuscular tone of the upper airway dilator muscles of patients with OSA during sleep. Data from previous feasibility studies and randomised controlled trials have helped to identify a subgroup of patients who are "responders" to this treatment. However, further investigations are required to assess usability, functionality and task accomplishment of this novel treatment. Consideration of these factors in the study design of future clinical trials will strengthen research methodology and protocols, improve patient related outcome measures and assessments, to optimise this emerging therapeutical option. In this review, we will introduce a conceptual framework for the TESLA home programme highlighting qualitative aspects and outcomes.

Uvulopalatopharyngoplasty reduces the incidence of depression caused by obstructive sleep apnea

OBJECTIVE

To investigate the increase in the incidence of depression in patients with obstructive sleep apnea (OSA) and its preventability by uvulopalatopharyngoplasty (UPPP).

METHODS

In this retrospective cohort study, data from the Korea National Health Insurance Corporation were analyzed. A total of 160,840 participants (age ≥ 20 years) who were newly diagnosed with OSA between 2007 and 2014 were included. The participants were classified into a group that underwent UPPP (UPPP group, n = 19,773) and a group that did not undergo surgical treatment (no surgery group, n = 141,067). Propensity score matching by age and sex was used to select the control group of 804,200 subjects. The mean follow-up duration was 4.6 ± 2.3 years. The primary endpoint was newly diagnosed depression.

RESULTS

The incidence of depression was higher in patients with OSA than in controls (hazard ratio [HR]: 1.678, 95% confidence interval [CI]: 1.650-1.706). The UPPP group was still at a higher risk of depression than was the control group (HR: 1.535, 95% CI: 1.463-1.610), but the HR was statistically lower than that in the no surgery group (HR: 1.694, 95% CI: 1.665-1.724).

CONCLUSION

OSA increases the incidence of depression, which may be prevented to some extent by UPPP.

LEVEL OF EVIDENCE

2b Laryngoscope, 129:1005-1009, 2019.

Intermittent Hypoxia Mimicking Sleep Apnea Increases Passive Stiffness of Myocardial Extracellular Matrix. A Multiscale Study

Background: Tissue hypoxia-reoxygenation characterizes obstructive sleep apnea (OSA), a very prevalent respiratory disease associated with increased cardiovascular morbidity and mortality. Experimental studies indicate that intermittent hypoxia (IH) mimicking OSA induces oxidative stress and inflammation in heart tissue at the cell and molecular levels. However, it remains unclear whether IH modifies the passive stiffness of the cardiac tissue extracellular matrix (ECM). Aim: To investigate multiscale changes of stiffness induced by chronic IH in the ECM of left ventricular (LV) myocardium in a murine model of OSA. Methods: Two-month and 18-month old mice (N = 10 each) were subjected to IH (20% O₂ 40 s-6% O₂ 20 s) for 6 weeks (6 h/day). Corresponding control groups for each age were kept under normoxia. Fresh LV myocardial strips (∼7 mm × 1 mm × 1 mm) were prepared, and their ECM was obtained by decellularization. Myocardium ECM macroscale mechanics were measured by performing uniaxial stress-strain tensile tests. Strip macroscale stiffness was assessed as the stress value (σ) measured at 0.2 strain and Young's modulus (E_M) computed at 0.2 strain by fitting Fung's constitutive model to the stress-strain relationship. ECM stiffness was characterized at the microscale as the Young's modulus (E_m) measured in decellularized tissue slices (∼12 μm tick) by atomic force microscopy. Results: Intermittent hypoxia induced a ∼1.5-fold increase in σ (p < 0.001) and a ∼2.5-fold increase in E_M (p < 0.001) of young mice as compared with normoxic controls. In contrast, no significant differences emerged in E_m among IH-exposed and normoxic mice. Moreover, the mechanical effects of IH on myocardial ECM were similar in young and aged mice. Conclusion: The marked IH-induced increases in macroscale stiffness of LV myocardium ECM suggests that the ECM plays a role in the cardiac dysfunction induced by OSA. Furthermore, absence of any significant effects of IH on the microscale ECM stiffness suggests that the significant increases in macroscale stiffening are primarily mediated by 3D structural ECM remodeling.

Obstructive Sleep Apnea Severity Affects Amyloid Burden in Cognitively Normal Elderly. A Longitudinal Study

RATIONALE

Recent evidence suggests that obstructive sleep apnea (OSA) may be a risk factor for developing mild cognitive impairment and Alzheimer's disease. However, how sleep apnea affects longitudinal risk for Alzheimer's disease is less well understood.

OBJECTIVES

To test the hypothesis that there is an association between severity of OSA and longitudinal increase in amyloid burden in cognitively normal elderly.

METHODS

Data were derived from a 2-year prospective longitudinal study that sampled community-dwelling healthy cognitively normal elderly. Subjects were healthy volunteers between the ages of 55 and 90, were nondepressed, and had a consensus clinical diagnosis of cognitively normal. Cerebrospinal fluid amyloid β was measured using ELISA. Subjects received Pittsburgh compound B positron emission tomography scans following standardized procedures. Monitoring of OSA was completed using a home sleep recording device.

MEASUREMENTS AND MAIN RESULTS

We found that severity of OSA indices (AHIall [F1,88 = 4.26; P < 0.05] and AHI4% [F1,87 = 4.36; P < 0.05]) were associated with annual rate of change of cerebrospinal fluid amyloid β42 using linear regression after adjusting for age, sex, body mass index, and apolipoprotein E4 status. AHIall and AHI4% were not associated with increases in ADPiB-mask (Alzheimer's disease vulnerable regions of interest Pittsburg compound B positron emission tomography mask) most likely because of the small sample size, although there was a trend for AHIall (F1,28 = 2.96, P = 0.09; and F1,28 = 2.32, not significant, respectively).

CONCLUSIONS

In a sample of cognitively normal elderly, OSA was associated with markers of increased amyloid burden over the 2-year follow-up. Sleep fragmentation and/or intermittent hypoxia from OSA are likely candidate mechanisms. If confirmed, clinical interventions for OSA may be useful in preventing amyloid build-up in cognitively normal elderly.