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Kwon Y, Tzeng WS, Seo J, Logan JG, Tadic M, Lin GM, Martinez-Garcia MA, Pengo M, Liu X, Cho Y, Drager LF, Healy W, Hong GR. Obstructive sleep apnea and hypertension; critical overview. Clin Hypertens 2024; 30:19. [PMID: 39090691 PMCID: PMC11293186 DOI: 10.1186/s40885-024-00276-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 05/22/2024] [Indexed: 08/04/2024] Open
Abstract
Obstructive sleep apnea (OSA) and hypertension are two important modifiable risk factors for cardiovascular disease and mortality. Numerous studies have highlighted the interplay between these two conditions. We provide a critical review of the current literature on the role of the OSA as a risk factor for hypertension and its effect on blood pressure (BP). We discuss several key topics: the effect of OSA on nocturnal BP, BP response to continuous positive airway pressure (CPAP) treatment, CPAP effect on BP in refractory hypertension, the role of OSA in BP variability (BPV), and maladaptive cardiac remodeling mediated by OSA's effect on BP. Finally, we discuss the unique aspects of ethnicity and social determinants of health on OSA with a focus on Asian populations and the disparity in BP control and cardiovascular outcomes.
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Affiliation(s)
- Younghoon Kwon
- Department of Medicine, University of Washington, Seattle, WA, USA.
- Division of Cardiology, University of Washington, Seattle, WA, USA.
| | - William S Tzeng
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Jiwon Seo
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea
| | - Jeongok Gang Logan
- Department of Acute & Specialty Care, University of Virginia School of Nursing, Charlottesville, VA, USA
| | - Marijana Tadic
- Klinik Für Innere Medizin II, Universitätsklinikum Ulm, Ulm, Germany
| | - Gen-Min Lin
- Department of Medicine, Hualien Armed Forces General Hospital, Hualien, Taiwan
- Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | | | - Martino Pengo
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, S.Luca Hospital, Milan, Italy
| | - Xiaoyue Liu
- Johns Hopkins School of Nursing, Johns Hopkins University, Baltimore, MD, USA
| | - Yeilim Cho
- Department of Sleep Medicine, University of Washington, Seattle, WA, USA
- Department of Sleep Medicine, Veteran's Affairs Puget Sound Healthcare System, Seattle, WA, USA
| | - Luciano F Drager
- Hypertension Unit, Heart Institute, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - William Healy
- Division of Pulmonary, Critical Care, Sleep Medicine, Medical College of Georgia, Augusta, GA, USA
| | - Geu-Ru Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea.
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Wang L, Liu H, Zhou L, Zheng P, Li H, Zhang H, Liu W. Association of Obstructive Sleep Apnea with Nonalcoholic Fatty Liver Disease: Evidence, Mechanism, and Treatment. Nat Sci Sleep 2024; 16:917-933. [PMID: 39006248 PMCID: PMC11244635 DOI: 10.2147/nss.s468420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 06/22/2024] [Indexed: 07/16/2024] Open
Abstract
Obstructive sleep apnea (OSA), a common sleep-disordered breathing condition, is characterized by intermittent hypoxia (IH) and sleep fragmentation and has been implicated in the pathogenesis and severity of nonalcoholic fatty liver disease (NAFLD). Abnormal molecular changes mediated by IH, such as high expression of hypoxia-inducible factors, are reportedly involved in abnormal pathophysiological states, including insulin resistance, abnormal lipid metabolism, cell death, and inflammation, which mediate the development of NAFLD. However, the relationship between IH and NAFLD remains to be fully elucidated. In this review, we discuss the clinical correlation between OSA and NAFLD, focusing on the molecular mechanisms of IH in NAFLD progression. We meticulously summarize clinical studies evaluating the therapeutic efficacy of continuous positive airway pressure treatment for NAFLD in OSA. Additionally, we compile potential molecular biomarkers for the co-occurrence of OSA and NAFLD. Finally, we discuss the current research progress and challenges in the field of OSA and NAFLD and propose future directions and prospects.
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Affiliation(s)
- Lingling Wang
- Department of Respiratory and Critical Care Medicine, Key Laboratory of Pulmonary Diseases of Health Ministry, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Huiguo Liu
- Department of Respiratory and Critical Care Medicine, Key Laboratory of Pulmonary Diseases of Health Ministry, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Ling Zhou
- Department of Respiratory and Critical Care Medicine, Key Laboratory of Pulmonary Diseases of Health Ministry, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Pengdou Zheng
- Department of Respiratory and Critical Care Medicine, Key Laboratory of Pulmonary Diseases of Health Ministry, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Hai Li
- Department of Geriatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
- Key Laboratory of Vascular Aging, Ministry of Education, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Huojun Zhang
- Department of Respiratory and Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, People’s Republic of China
| | - Wei Liu
- Department of Geriatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
- Key Laboratory of Vascular Aging, Ministry of Education, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
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Schmickl CN, Orr JE, Sands SA, Alex RM, Azarbarzin A, McGinnis L, White S, Mazzotti DR, Nokes B, Owens RL, Gottlieb DJ, Malhotra A. Loop Gain as a Predictor of Blood Pressure Response in Patients Treated for Obstructive Sleep Apnea: Secondary Analysis of a Clinical Trial. Ann Am Thorac Soc 2024; 21:296-307. [PMID: 37938917 PMCID: PMC10848904 DOI: 10.1513/annalsats.202305-437oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 11/06/2023] [Indexed: 11/10/2023] Open
Abstract
Rationale: Randomized trials have shown inconsistent cardiovascular benefits from obstructive sleep apnea (OSA) therapy. Intermittent hypoxemia can increase both sympathetic nerve activity and loop gain ("ventilatory instability"), which may thus herald cardiovascular treatment benefit. Objectives: To test the hypothesis that loop gain predicts changes in 24-hour mean blood pressure (MBP) in response to OSA therapy and compare its predictive value against that of other novel biomarkers. Methods: The HeartBEAT (Heart Biomarker Evaluation in Apnea Treatment) trial assessed the effect of 12 weeks of continuous positive airway pressure (CPAP) versus oxygen versus control on 24-hour MBP. We measured loop gain and hypoxic burden from sleep tests and identified subjects with a sleepy phenotype using cluster analysis. Associations between biomarkers and 24-h MBP were assessed in the CPAP/oxygen arms using linear regression models adjusting for various covariates. Secondary outcomes and predictors were analyzed similarly. Results: We included 93 and 94 participants in the CPAP and oxygen arms, respectively. Overall, changes in 24-hour MBP were small, but interindividual variability was substantial (mean [standard deviation], -2 [8] and 1 [8] mm Hg in the CPAP and oxygen arms, respectively). Higher loop gain was significantly associated with greater reductions in 24-hour MBP independent of covariates in the CPAP arm (-1.5 to -1.9 mm Hg per 1-standard-deviation increase in loop gain; P ⩽ 0.03) but not in the oxygen arm. Other biomarkers were not associated with improved cardiovascular outcomes. Conclusions: To our knowledge, this is the first study suggesting that loop gain predicts blood pressure response to CPAP therapy. Eventually, loop gain estimates may facilitate patient selection for research and clinical practice. Clinical trial registered with www.clinicaltrials.gov (NCT01086800).
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Affiliation(s)
- Christopher N Schmickl
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, San Diego, California
| | - Jeremy E Orr
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, San Diego, California
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Raichel M Alex
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lana McGinnis
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, San Diego, California
| | - Stephanie White
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, San Diego, California
| | - Diego R Mazzotti
- Division of Medical Informatics and
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas; and
| | - Brandon Nokes
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, San Diego, California
| | - Robert L Owens
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, San Diego, California
| | - Daniel J Gottlieb
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, San Diego, California
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Modi NS, Bajoria PS, Dave PA, Rohit RK, Tibrewal C, Patel P, Gandhi SK, Gutlapalli SD, Diaz K, Nfonoyim J. Effectiveness of Continuous Positive Airway Pressure in Treating Hypertension in Obstructive Sleep Apnea: A Traditional Review. Cureus 2023; 15:e42111. [PMID: 37602019 PMCID: PMC10436127 DOI: 10.7759/cureus.42111] [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: 06/18/2023] [Accepted: 07/19/2023] [Indexed: 08/22/2023] Open
Abstract
Almost one billion individuals worldwide suffer from obstructive sleep apnea (OSA). The most widely used treatment for OSA has been continuous positive airway pressure (CPAP), but its effect on blood pressure (BP) has been challenged. Our review aims to evaluate the effects of treating OSA with CPAP on BP and BP-related morbidities in adult hypertensive patients. Medical subject headings (MeSH) terminology was used to search the PubMed Central, MEDLINE, and PubMed databases for articles on the use of CPAP in OSA patients with hypertension. We selected various forms of academic writing, encompassing complete texts that were published in the English language. The study included a total of 21 papers. OSA is a serious health concern associated with a higher risk of cardiovascular disease, kidney disease, pulmonary hypertension, and aortic stiffness, which is brought on by the periodic hypoxia caused by nocturnal respiratory episodes. For individuals with moderate-to-severe OSA, CPAP therapy has been shown to have a considerable long-term benefit with a median drop of 11 mm Hg, and high adherence results in a decrease in diastolic BP. CPAP therapy directly lowers BP in OSA patients with a body mass index (BMI) of more than 30 kg/m2 and has also demonstrated improvement in early signs of atherosclerosis with lower nocturnal systolic BP levels. OSA patients with resistant hypertension also experienced lower BP after using CPAP for a year. Therefore, our findings suggest that obesity, hypersomnolence, high nocturnal BP, prolonged CPAP usage, and resistant hypertension may all have a major impact on the BP response to CPAP therapy in individuals with severe OSA.
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Affiliation(s)
| | - Parth S Bajoria
- Department of Internal Medicine, GMERS (Gujarat Medical Education and Research Society) Medical College Gandhinagar, Gandhinagar, IND
| | | | - Ralph Kingsford Rohit
- Department of Internal Medicine, Dayanand Medical College and Hospital, Ludhiana, IND
| | - Charu Tibrewal
- Department of Internal Medicine, Civil Hospital Ahmedabad, Ahmedabad, IND
| | - Priyansh Patel
- Department of Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Department of Internal Medicine, Medical College Baroda, Vadodara, IND
| | - Siddharth Kamal Gandhi
- Department of Internal Medicine, Shri M.P. Shah Government Medical College, Jamnagar, IND
| | - Sai Dheeraj Gutlapalli
- Department of Internal Medicine, Richmond University Medical Center, New York City, USA
- Department of Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Keith Diaz
- Department of Pulmonary and Critical Care Medicine, Richmond University Medical Center, New York City, USA
| | - Jay Nfonoyim
- Department of Pulmonary and Critical Care Medicine, Richmond University Medical Center, New York City, USA
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5
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Meng Z, Chen Y, Yang T, Sun B, Luo C, Wei G, Xie X, Gu Y, Ding N, Zhang X, Xu J. New perspective on exploring the predictive factors of blood pressure reduction during CPAP treatment in people with severe OSA and hypertension: a prospective observational study. BMJ Open Respir Res 2023; 10:10/1/e001560. [PMID: 37169401 DOI: 10.1136/bmjresp-2022-001560] [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: 11/21/2022] [Accepted: 04/28/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND The predictive factors of blood pressure (BP) response to continuous positive airway pressure (CPAP) in obstructive sleep apnoea (OSA) are still being explored. We aimed to assess the antihypertensive effect of CPAP considering the obstructive respiratory event-triggered BP surge profiles in 130 subjects with severe OSA and untreated hypertension. METHODS Nocturnal BP was monitored continuously and synchronised with polysomnography. Event-triggered BP surge profiles were studied: BP surge as the value of event-related systolic BP (SBP) elevation; BP index as the number of BP surge events of ≥10 mm Hg per hour. Patients were then divided into two groups according to the median BP index (high and low BP surge groups) and assigned to 4 weeks of CPAP. Changes in BPs and plasma biomarkers were compared. After the initial evaluation, patients with a better BP response in the high BP surge group were then followed up for the second evaluation at 24 months. RESULTS Overall, a modest decrease was observed in both office and asleep BPs at the 4-week follow-up; however, BPs dropped more markedly in patients in the high BP surge group than those in the low BP surge group, in both office SBP (5.3 mm Hg vs 2.2 mm Hg, p=0.003) and diastolic BP (4.0 mm Hg vs 1.2 mm Hg, p<0.001), especially the asleep SBP (9.0 mm Hg vs 2.1 mm Hg, p<0.001). For 30 cases in the high BP surge group, optimal BP control was achieved in 60.0% of patients and BP<140/90 mm Hg reached up to 83.3% after 24 months of CPAP. Linear regression revealed that BP index was significantly associated with BP decrease during CPAP treatment. CONCLUSIONS Our results suggested that high event-triggered BP surge was a sensitive predictor of BP response to CPAP in patients with severe OSA and untreated hypertension. TRIAL REGISTRATION NUMBER Clinical Trials.gov Identifier: NCT03246022; https://clinicaltrials.gov/ct2/show/NCT03246022?term=NCT+03246022&draw=2&rank=1.
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Affiliation(s)
- Zili Meng
- Department of Respiratory and Critical Care Medicine, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huaian, China
| | - Ying Chen
- Department of Respiratory and Critical Care Medicine, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huaian, China
| | - Ting Yang
- Department of Respiratory and Critical Care Medicine, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huaian, China
| | - Bo Sun
- Department of Respiratory and Critical Care Medicine, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huaian, China
| | - Chao Luo
- Department of Respiratory and Critical Care Medicine, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huaian, China
| | - Guihong Wei
- Department of Respiratory and Critical Care Medicine, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huaian, China
| | - Xiaochen Xie
- Department of Respiratory and Critical Care Medicine, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huaian, China
| | - Yang Gu
- Department of Respiratory and Critical Care Medicine, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huaian, China
| | - Ning Ding
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xilong Zhang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jing Xu
- Department of Respiratory and Critical Care Medicine, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huaian, China
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Personalized Medicine and Obstructive Sleep Apnea. J Pers Med 2022; 12:jpm12122034. [PMID: 36556255 PMCID: PMC9781564 DOI: 10.3390/jpm12122034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/27/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022] Open
Abstract
Obstructive sleep apnea (OSA) is a common disease that is often under-diagnosed and under-treated in all ages. This is due to differences in morphology, diversity in clinical phenotypes, and differences in diagnosis and treatment of OSA in children and adults, even among individuals of the same age. Therefore, a personalized medicine approach to diagnosis and treatment of OSA is necessary for physicians in clinical practice. In children and adults without serious underlying medical conditions, polysomnography at sleep labs may be an inappropriate and inconvenient testing modality compared to home sleep apnea testing. In addition, the apnea-hypopnea index should not be considered as a single parameter for making treatment decisions. Thus, the treatment of OSA should be personalized and based on individual tolerance to sleep-quality-related parameters measured by the microarousal index, harmful effects of OSA on the cardiovascular system related to severe hypoxia, and patients' comorbidities. The current treatment options for OSA include lifestyle modification, continuous positive airway pressure (CPAP) therapy, oral appliance, surgery, and other alternative treatments. CPAP therapy has been recommended as a cornerstone treatment for moderate-to-severe OSA in adults. However, not all patients can afford or tolerate CPAP therapy. This narrative review seeks to describe the current concepts and relevant approaches towards personalized management of patients with OSA, according to pathophysiology, cluster analysis of clinical characteristics, adequate combined therapy, and the consideration of patients' expectations.
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Zagorski T, Arzt M, Stadler S. Obstruktive Schlafapnoe und arterielle Hypertonie. SOMNOLOGIE 2022. [DOI: 10.1007/s11818-022-00358-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Zusammenfassung
Hintergrund
In Deutschland leiden rund 19 Mio. Patienten an einer diagnostizierten arteriellen Hypertonie (aHT). Die Schnittmenge zwischen Menschen mit aHT und obstruktiver Schlafapnoe (OSA) ist groß. Aufwachreaktionen und Hypoxämie im Rahmen einer OSA können zu einem gesteigerten Sympathikotonus und endothelialer Dysfunktion und somit zu aHT führen.
Fragestellung
Der vorliegende Übersichtsartikel soll die Zusammenhänge zwischen OSA und aHT sowie Behandlungsmöglichkeiten darstellen.
Materialien und Methoden
Es erfolgte eine Literaturrecherche von Original- und Übersichtsartikeln, die bis 2021 in der PubMed-Datenbank veröffentlicht wurden.
Ergebnisse
Obstruktive Schlafapnoe kann sowohl die Entstehung als auch die Verschlechterung einer aHT verursachen. Betroffene profitieren von einer CPAP-Behandlung mit einer durchschnittlichen Senkung des systolischen Blutdrucks um −4,4 mm Hg sowie des diastolischen Blutdrucks um −2,9 mm Hg. Prädiktoren für eine Reduktion des Blutdrucks unter kontinuierlicher Positivdrucktherapie (CPAP) sind junges Alter, therapieresistente aHT, schwere OSA-bedingte Sauerstoffentsättigungen und ein „Non-Dipping-Blutdruckmuster“.
Schlussfolgerung
Die adäquate Behandlung einer aHT fordert häufig einen multimodalen Ansatz. Neben einer medikamentösen antihypertensiven Therapie und einer Modifikation des Lebensstils sollte auch die Diagnose und gegebenenfalls die Behandlung einer OSA berücksichtigt werden.
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Effect of CPAP treatment on BP in resistant hypertensive patients according to the BP dipping pattern and the presence of nocturnal hypertension. Hypertens Res 2021; 45:436-444. [PMID: 34952953 DOI: 10.1038/s41440-021-00762-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 08/14/2021] [Accepted: 08/19/2021] [Indexed: 11/08/2022]
Abstract
High heterogeneity in the blood pressure (BP) response to continuous positive airway pressure (CPAP) exists in patients with resistant hypertension (RH). Only nondipper normotensive and hypertensive patients exhibited BP reductions when treated with CPAP; the baseline BP dipping pattern has been proposed as a predictor of BP response to CPAP but has never been explored in patients with RH. This study aimed to assess the effect of CPAP on BP in subjects with RH with respect to BP dipping pattern or nocturnal hypertension. This is an ancillary study of the SARAH study. RH subjects with an apnea/hypopnea index (AHI) ≥ 15/h and who received CPAP treatment for 1 year were included. Subjects underwent a sleep study and ambulatory BP monitoring (ABPM) at baseline and at the 1-year follow-up. Eighty-nine RH subjects were included. The subjects were mainly male (77.5%) and obese, with a mean age of 66 years (25th-75th percentile; 59.0; 70.0) and an AHI of 32.7/h (25th-75th percentile; 25.0; 54.7). A total of 68.5% of participants were nondippers, and 71.9% had nocturnal hypertension. After 1 year of CPAP, no significant differences in ABPM parameters were observed between dippers and nondippers. According to nighttime BP, subjects with nocturnal normotension did not show significant changes in ABPM parameters, while nocturnal hypertensive subjects achieved a significant reduction in mean nighttime BP of -4.38 mmHg (-7.10 to -1.66). The adjusted difference between groups was 3.04 (-2.25 to 8.34), which was not significant. This study shows that the BP response to CPAP in patients with RH does not differ according to the BP dipping pattern (dipper and nondipper) and suggests a differential response according to the presence of nocturnal hypertension (ClinicalTrials.gov: NCT03002558).
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9
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Imayama I, Gupta A, Yen PS, Chen YF, Keenan B, Townsend RR, Chirinos JA, Weaver FM, Carley DW, Kuna ST, Prasad B. Socioeconomic status impacts blood pressure response to positive airway pressure treatment. J Clin Sleep Med 2021; 18:1287-1295. [PMID: 34931603 PMCID: PMC9059597 DOI: 10.5664/jcsm.9844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Positive airway pressure (PAP) treatment of obstructive sleep apnea (OSA) reduces blood pressure (BP). Retrospective data suggest that African Americans (AA), a group at high-risk for hypertensive organ dysfunction, may have a greater BP response to PAP therapy than European Americans (EA). We examined the difference in 24-hour BP response to three months of PAP treatment between AA and EA. METHODS Participants (N=259, 161 AA and 98 EA) with apnea-hypopnea index (AHI) ≥15/hour from two prospective cohorts were included. T-tests and multiple linear regression were used to examine BP outcomes in AA vs. EA, adjusting for PAP adherence, socioeconomic status (SES), and baseline characteristics. RESULTS Participants were middle-aged (mean ± standard deviation, 53.8±9.3 years), 86% (227) men, AHI 35.6±19.2/hour, and PAP adherence of 3.36±2.24 hours/day. The reductions in 24-hour systolic and diastolic BP (mm Hg) were not different in AA vs. EA (systolic=-1.13±12.1 vs. -0.61±12.8, p=0.80 and diastolic=-0.74±7.9 vs. -0.80±7.4, p=0.96), and race was not a predictor of 24-hour systolic or diastolic BP reduction (p=0.75 and 0.54). SES and PAP adherence demonstrated a significant interaction; low SES was associated with an increase in 24-hour systolic BP (β=19.3, p=0.03) in the absence of PAP use but a greater reduction in 24-hour systolic BP with higher PAP adherence (β=-3.96, p=0.03). CONCLUSIONS 24-hour BP response to PAP treatment is similar in AA and EA. Adherence to PAP treatment is more effective in improving 24-hour systolic BP in those with low SES. The study was a clinical trial. Clinical Trial Registration: NCT01960465 and NCT01578031.
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Affiliation(s)
- Ikuyo Imayama
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Ahana Gupta
- GPPA Medical Scholars Program, University of Illinois at Chicago, Chicago, IL
| | - Pei-Shan Yen
- Division of Epidemiology & Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, IL
| | - Yi-Fan Chen
- Biostatistics Core, Center for Clinical and Translational Science, University of Illinois at Chicago, Chicago, IL
| | - Brendan Keenan
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Raymond R Townsend
- Division of Nephrology, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Julio A Chirinos
- Division of Cardiology, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Frances M Weaver
- Center of Innovation for Complex Chronic Health Care (CINCCH), Hines VA, Hines, IL and Parkinson School of Health Sciences and Public Health, Loyola University, Chicago, IL
| | - David W Carley
- Department of Biobehavioral Health Science, University of Illinois at Chicago, Chicago, IL
| | - Samuel T Kuna
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA.,Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Bharati Prasad
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, IL.,Department of Medicine, Jesse Brown VA Medical Center, Chicago, IL
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10
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Sutherland K, Dissanayake HU, Trzepizur W, Gagnadoux F, Cistulli PA. Circadian blood pressure profile and blood pressure changes following oral appliance therapy for obstructive sleep apnoea. J Hypertens 2021; 39:2272-2280. [PMID: 34149014 DOI: 10.1097/hjh.0000000000002914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Oral appliance therapy for obstructive sleep apnoea (OSA) reduces blood pressure (BP) but there is little information on relationship to circadian BP pattern (nocturnal BP dipping or non-dipping). The aims of this study were to determine whether nocturnal dipping pattern influences BP changes following oral appliance therapy, and to determine the effect of oral appliance therapy on circadian BP pattern. METHODS Participants in two randomized trials of oral appliance therapy (1-2 months) with 24-h ambulatory BP monitoring (ABPM) data were included (N = 152). Nocturnal BP Dippers (nocturnal/diurnal SBP ratio <0.9) and non-dippers were compared for BP changes following oral appliance therapy and the effect of oral appliance therapy on nocturnal BP dipping was assessed. RESULTS Of 152 participants, 64.5% were dippers. Dippers were on average younger and less likely to be hypertensive (42 vs. 82.7%, P < 0.001). Nondippers showed greater reduction in nocturnal BP measures, related to higher BP measures at baseline. There was no difference in the relationship between treatment effectiveness and BP changes between groups. Oral appliance therapy converted only 23% of baseline non-dippers to a nocturnal dipping profile. CONCLUSION Baseline circadian BP profile influenced the BP response to oral appliance therapy, largely because of higher baseline BP in the non-dipper subgroup. Oral appliance therapy did not convert OSA patients to a more favourable circadian BP profile. Further work is required to understand the effect of oral appliance therapy on circadian BP profile and of the individuals who will receive cardiovascular benefit from oral appliance therapy.
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Affiliation(s)
- Kate Sutherland
- Sleep Research Group, Charles Perkins Centre & Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Camperdown
- Department of Respiratory & Sleep Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Hasthi U Dissanayake
- Sleep Research Group, Charles Perkins Centre & Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Camperdown
- Department of Respiratory & Sleep Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Wojciech Trzepizur
- University of Angers, INSERM UMR 1063 'SOPAM'
- Department of Respiratory and Sleep Medicine, University Hospital of Angers, Angers, France
| | - Frederic Gagnadoux
- University of Angers, INSERM UMR 1063 'SOPAM'
- Department of Respiratory and Sleep Medicine, University Hospital of Angers, Angers, France
| | - Peter A Cistulli
- Sleep Research Group, Charles Perkins Centre & Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Camperdown
- Department of Respiratory & Sleep Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
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11
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Crinion SJ, Kleinerova J, Kent B, Nolan G, Taylor CT, Ryan S, McNicholas WT. Non-dipping nocturnal blood pressure correlates with obstructive sleep apnoea severity in normotensive subjects and may reverse with therapy. ERJ Open Res 2021; 7:00338-2021. [PMID: 34409095 PMCID: PMC8365144 DOI: 10.1183/23120541.00338-2021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 06/09/2021] [Indexed: 11/09/2022] Open
Abstract
Background Obstructive sleep apnoea (OSA) is strongly associated with systemic hypertension, but there are limited data on the relationship with blood pressure (BP) in normotensive subjects. Here, we examined the relationship of OSA with nocturnal BP in a documented diurnal normotensive cohort, explored potential intermediate pathways and assessed the effects on BP of continuous positive airways pressure (CPAP) therapy. Methods 65 males referred for assessment of possible OSA and normotensive on 24-hour BP monitoring underwent overnight inpatient polysomnography (age 41±7 years, body mass index (BMI) 34±6 kg·m−2, apnoea–hypopnoea index (AHI) 14 (interquartile range 5–26)). Urine and serum were assessed for markers of sympathetic activation, renin–angiotensin–aldosterone system activity, oxidative stress, endothelial function and systemic inflammation. In a subset of patients, 24-hour BP monitoring was repeated after CPAP therapy. Results Within this normotensive cohort, night-time systolic and diastolic BP and nocturnal BP dip were highest in the fourth OSA severity quartile (p<0.05). Nocturnal BP dip correlated with AHI (r=−0.327, p<0.05) and oxygen desaturation index (ODI) (r=−0.371, p<0.05), but only ODI was an independent predictor of BP dip (B=–0.351, p<0.01) and non-dipping status (B=0.046, p<0.05). Overnight urinary norepinephrine correlated with nocturnal systolic BP (r=0.387, p<0.01) with a trend towards correlation with systolic dipping (p=0.087). In 20 CPAP-treated patients, night-time systolic BP decreased (p<0.05) and mean nocturnal BP dip increased (p≤0.05). Conclusion In this normotensive cohort, OSA severity was associated with higher nocturnal BP, which improved following CPAP therapy, and intermittent hypoxia was the most important OSA-related variable in this relationship. There is a strong association in a normotensive cohort between OSA and nocturnal blood pressure, with intermittent hypoxia as an important mechanistic pathwayhttps://bit.ly/2SFvWiB
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Affiliation(s)
- Sophie J Crinion
- Respirology and Sleep Medicine, Kingston Health Sciences Centre, Kingston, Canada.,Dept of Medicine, Queen's University, Kingston, Canada
| | - Jana Kleinerova
- Dept of Respiratory Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Brian Kent
- Dept of Respiratory Medicine, St James' Hospital, Dublin, Ireland
| | - Geraldine Nolan
- Dept of Respiratory and Sleep Medicine, St Vincent's University Hospital, Dublin, Ireland
| | - Cormac T Taylor
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Silke Ryan
- Dept of Respiratory and Sleep Medicine, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland.,These authors contributed equally
| | - Walter T McNicholas
- Dept of Respiratory and Sleep Medicine, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland.,These authors contributed equally
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12
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Zhang ZL, Duolikun D, Yao QL. Top 100 influential manuscripts in obstructive sleep apnea: a bibliometric analysis. Sleep Breath 2021; 26:37-45. [PMID: 33991308 DOI: 10.1007/s11325-021-02378-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/11/2021] [Accepted: 04/09/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to explore the characteristics of the top 100 influential manuscripts on obstructive sleep apnea (OSA). METHODS All manuscripts in English were searched from the Thomson Reuters Web of Science database by using OSA-related terms and ranked based on citation frequency. The top 100 influential manuscripts were selected and further analyzed by author, subject, journal, year of publication, country of origin, and institution. RESULTS A total of 42,878 manuscripts were searched from the Web of Science. The top 100 influential manuscripts were published from 2005 to 2017, with a total citation frequency of 38,463 and a median citation frequency of 303 (range: from 210 to 2, 707). The American Journal of Respiratory and Critical Care Medicine published the largest number of manuscripts from the top 100 (n = 18; 5340 citations), followed by Sleep (n = 11; 3516 citations) and Chest (n = 7; 1784 citations). The most cited manuscript (Marin, J.M et al., Lancet 2005; 2707 citations) mainly analyzed long-term cardiovascular outcomes in men with OSA with/without continuous positive airway pressure. The most prevalent subject was associated diseases (n = 41), followed by treatments (n = 40). Most of the manuscripts were original articles (n = 63) based on observational clinical studies and published from American institutions (n = 60). CONCLUSIONS Our study identified the top 100 influential manuscripts on OSA and provides insights into the characteristics of the most highly cited manuscripts to improve our understanding and management of OSA.
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Affiliation(s)
- Zhen-Lian Zhang
- Department of Physiology, School of Basic Medical Sciences, Xinjiang Medical University, No. 393 Xinyi Road, Urumqi, Xinjiang, China
| | - Dilihumaier Duolikun
- Department of Physiology, School of Basic Medical Sciences, Xinjiang Medical University, No. 393 Xinyi Road, Urumqi, Xinjiang, China
| | - Qiao-Ling Yao
- Department of Physiology, School of Basic Medical Sciences, Xinjiang Medical University, No. 393 Xinyi Road, Urumqi, Xinjiang, China.
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13
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A Phenotypic Approach for Personalised Management of Obstructive Sleep Apnoea. CURRENT OTORHINOLARYNGOLOGY REPORTS 2021. [DOI: 10.1007/s40136-021-00346-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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14
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Lui MMS, Tse HF, Lam DCL, Lau KK, Chan CWS, Ip MSM. Continuous positive airway pressure improves blood pressure and serum cardiovascular biomarkers in obstructive sleep apnoea and hypertension. Eur Respir J 2021; 58:13993003.03687-2020. [PMID: 33795324 DOI: 10.1183/13993003.03687-2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 03/23/2021] [Indexed: 11/05/2022]
Abstract
RATIONALE The impact of treatment for obstructive sleep apnoea (OSA) on reduction of cardiovascular risk is unclear. This study aimed to examine the effect of continuous positive airway pressure (CPAP) on ambulatory blood pressure (BP) and subclinical myocardial injury in subjects with OSA and hypertension. METHODS Subjects with hypertension requiring at least three anti-hypertensive medications and moderate-severe OSA were enrolled. Eligible subjects were randomized (1:1) to receive either CPAP treatment or control (no CPAP) for eight weeks. Changes in ambulatory BP and serum biomarkers were compared. Stratified analysis according to circadian BP pattern was performed. MAIN RESULTS Ninety two subjects (75% men; age, 51±8 years; apnoea-hypopnoea index 40±8 events·h-1, taking average of 3.4 anti-hypertensive drugs [range 3-6]) were randomised. The group on CPAP treatment, compared to the control group, demonstrated significant reduction in 24-h systolic BP (-4.4 mmHg, 95% CI -8.7 to -0.1, p=0.046), 24-h diastolic BP (-2.9 mmHg, 95% CI -5.5 to -0.2, p=0.032), daytime systolic BP (-5.4 mmHg, -9.7 to -1.0, p=0.016) and daytime diastolic BP (-3.4 mmHg, 95% CI -6.1 to -0.8, p=0.012). CPAP treatment was associated with significant BP lowering only in non-dippers, but not in dippers. Serum troponin I (mean difference -1.74 pg·mL-1, 95% CI -2.97 to -0.5, p=0.006) and brain natriuretic peptide (-9.1 pg·mL-1, 95% CI -17.6 to -0.6, p=0.036) were significantly reduced in CPAP compared to control group. CONCLUSION In a cohort with OSA and multiple cardiovascular risk factors including difficult-to-control hypertension, short-term CPAP treatment improved ambulatory BP and alleviated subclinical myocardial injury and strain.
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Affiliation(s)
- Macy Mei-Sze Lui
- Division of Respiratory and Critical Care Medicine, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, Hong Kong
| | - Hung-Fat Tse
- Division of Cardiology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, Hong Kong
| | - David Chi-Leung Lam
- Division of Respiratory and Critical Care Medicine, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, Hong Kong
| | - Kui-Kai Lau
- Division of Neurology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, Hong Kong
| | - Carmen Wing-Sze Chan
- Division of Cardiology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, Hong Kong
| | - Mary Sau-Man Ip
- Division of Respiratory and Critical Care Medicine, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, Hong Kong
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15
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Pio-Abreu A, Moreno H, Drager LF. Obstructive sleep apnea and ambulatory blood pressure monitoring: current evidence and research gaps. J Hum Hypertens 2021; 35:315-324. [PMID: 33414503 DOI: 10.1038/s41371-020-00470-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 11/06/2020] [Accepted: 12/07/2020] [Indexed: 01/29/2023]
Abstract
Obstructive Sleep Apnea (OSA) is a common condition characterized by intermittent collapse of the upper airway during sleep, resulting in partial (hypopnoeas) and total obstructions (apneas). These respiratory events observed in OSA may trigger multiple pathways involved in the blood pressure (BP) instability during the night and potentially influencing daytime BP as well (carry-over effects). This review provides an update about the impact of OSA and its treatments on 24-h BP control. Overall, there is growing evidence suggest that OSA is associated with higher frequency of nondipping BP pattern and nocturnal hypertension in a dose-dependent manner. The presence of nondiping BP (especially the reverse pattern) is independently associated with OSA regardless of sleep-related symptoms suggesting a potential tool for screening OSA in patients with clinical indication for performing ABPM. Beyond dipping BP, preliminary evidence associated OSA with white-coat effect and higher frequency of masked hypertension and BP variability than the control group (no OSA). Unfortunately, most of the evidence on the evidence addressing the impact of OSA treatment on BP was limited to office measurements. In the last years, data from observational and randomized studies pointed that CPAP is able to promote 24-h BP decrease especially in patients with resistant and refractory hypertension. A randomized trial suggests that CPAP is able to decrease the rate of masked hypertension as compared to no treatment in patients with severe OSA. Interestingly, nondipping BP is a good predictor of BP response to CPAP making ABPM an interesting tool for better OSA management.
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Affiliation(s)
- Andrea Pio-Abreu
- Hypertension Unit, Renal Division, University of São Paulo Medical School, Sao Paulo, Brazil
| | - Heitor Moreno
- Laboratory of Cardiovascular Pharmacology, Faculty of Medical Sciences, University of Campinas (Unicamp), Campinas, Brazil
| | - Luciano F Drager
- Hypertension Unit, Renal Division, University of São Paulo Medical School, Sao Paulo, Brazil. .,Hypertension Unit, Heart Institute (InCor), University of São Paulo Medical School, Sao Paulo, Brazil.
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16
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Fujino Y, Oka Y, Wakamura T. Seasonal effects on the continuous positive airway pressure adherence of patients with obstructive sleep apnea. Sleep Med 2021; 80:126-133. [PMID: 33596526 DOI: 10.1016/j.sleep.2021.01.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 01/12/2021] [Accepted: 01/15/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This study examined seasonal differences in continuous positive airway pressure (CPAP) therapy adherence among patients with obstructive sleep apnea (OSA). METHODS Patients aged ≥20 years with OSA who had used CPAP devices on the automatic setting for >12 consecutive months (n = 141) were included in this retrospective study from December 2015-2016. The information of CPAP use (pressure, hours of actual use) was extracted from database downloaded from patients' CPAP devices. Patients were divided into adherent and non-adherent groups using the cutoff point of 70% CPAP use for ≥4 h daily over the 1-year study period. CPAP use data were averaged for each season. RESULTS Patients in the adherent group were significantly older than those in the non-adherent group (p < 0.001). In the adherent group, the rate of ≥4 h daily CPAP use was significantly lower, the daily duration of CPAP use was significantly shorter, and the residual apnea-hypopnea index (AHI; events/hour) was significantly higher in summer than in other seasons (all p < 0.001). In the non-adherent group, the duration of daily CPAP use and the AHI differed significantly between winter and summer (p = 0.008 and p < 0.001, respectively). CONCLUSIONS Seasonal changes were associated with the CPAP adherence of patients with OSA. The study findings suggest that there is possibility of increasing the duration of CPAP use by adjusting the bedroom environment in hot and humid seasons.
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Affiliation(s)
- Yoko Fujino
- Environmental Health Nursing, Human Health Sciences, Graduate School of Medicine, Kyoto University, 53, Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan; Center for Sleep Medicine, Ehime University Hospital, 454, Toon-city, Ehime, 791-0204, Japan.
| | - Yasunori Oka
- Center for Sleep Medicine, Ehime University Hospital, 454, Toon-city, Ehime, 791-0204, Japan
| | - Tomoko Wakamura
- Environmental Health Nursing, Human Health Sciences, Graduate School of Medicine, Kyoto University, 53, Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
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17
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Green M, Ken-Dror G, Fluck D, Sada C, Sharma P, Fry CH, Han TS. Meta-analysis of changes in the levels of catecholamines and blood pressure with continuous positive airway pressure therapy in obstructive sleep apnea. J Clin Hypertens (Greenwich) 2020; 23:12-20. [PMID: 32970922 PMCID: PMC8030100 DOI: 10.1111/jch.14061] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 09/02/2020] [Accepted: 09/06/2020] [Indexed: 12/22/2022]
Abstract
Stress from obstructive sleep apnea (OSA) stimulates catecholamine release consequently exacerbating hypertension. However, different studies have shown a conflicting impact of continuous positive airway pressure (CPAP) treatment in patients with OSA on catecholamine levels and blood pressure. We aimed to examine changes to catecholamine levels and blood pressure in response to CPAP treatment. We conducted a meta‐analysis of data published up to May 2020. The quality of the studies was evaluated using standard tools for assessing the risk of bias. Meta‐analysis was conducted using RevMan (v5.3) and expressed in standardized mean difference (SMD) for catecholamines and mean difference (MD) for systolic (SBP) and diastolic blood pressure (DBP). A total of 38 studies met our search criteria; they consisted of 14 randomized control trials (RCT) totaling 576 participants and 24 prospective cohort studies (PCS) of 547 participants. Mean age ranged between 41 and 62 year and body mass index between 27.2 and 35.1 kg/m2. CPAP treatment reduced 24‐hour urinary noradrenaline levels both in RCT (SMD = −1.1; 95% confidence interval (CI): −1.63 to − 0.56) and in PCS (SMD = 0.38 (CI: 0.24 to 0.53). SBP was also reduced by CPAP treatment in RCT (4.8 mmHg; CI: 2.0‐7.7) and in PCS (7.5 mmHg; CI: 3.3‐11.7). DBP was similarly reduced (3.0 mmHg; CI: 1.4‐4.6) and in PCS (5.1 mmHg; CI: 2.3‐8.0). In conclusion, CPAP treatment in patients with OSA reduces catecholamine levels and blood pressure. This suggests that sympathetic activity plays an intermediary role in hypertension associated with OSA‐related stress.
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Affiliation(s)
- Mackenzie Green
- Medical School, University of Glasgow, Glasgow, UK.,Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, UK
| | - Gie Ken-Dror
- Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, UK
| | - David Fluck
- Department of Cardiology, Ashford and St Peter's Hospitals NHS Foundation Trust, Chertsey, UK
| | - Charif Sada
- Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, UK
| | | | - Christopher H Fry
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, UK
| | - Thang S Han
- Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, UK.,Department of Endocrinology, Ashford and St Peter's Hospitals NHS Foundation Trust, Chertsey, UK
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18
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Ryan S, Cummins EP, Farre R, Gileles-Hillel A, Jun JC, Oster H, Pepin JL, Ray DW, Reutrakul S, Sanchez-de-la-Torre M, Tamisier R, Almendros I. Understanding the pathophysiological mechanisms of cardiometabolic complications in obstructive sleep apnoea: towards personalised treatment approaches. Eur Respir J 2020; 56:13993003.02295-2019. [PMID: 32265303 DOI: 10.1183/13993003.02295-2019] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 03/15/2020] [Indexed: 12/19/2022]
Abstract
In January 2019, a European Respiratory Society research seminar entitled "Targeting the detrimental effects of sleep disturbances and disorders" was held in Dublin, Ireland. It provided the opportunity to critically review the current evidence of pathophysiological responses of sleep disturbances, such as sleep deprivation, sleep fragmentation or circadian misalignment and of abnormalities in physiological gases such as oxygen and carbon dioxide, which occur frequently in respiratory conditions during sleep. A specific emphasis of the seminar was placed on the evaluation of the current state of knowledge of the pathophysiology of cardiovascular and metabolic diseases in obstructive sleep apnoea (OSA). Identification of the detailed mechanisms of these processes is of major importance to the field and this seminar offered an ideal platform to exchange knowledge, and to discuss pitfalls of current models and the design of future collaborative studies. In addition, we debated the limitations of current treatment strategies for cardiometabolic complications in OSA and discussed potentially valuable alternative approaches.
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Affiliation(s)
- Silke Ryan
- Pulmonary and Sleep Disorders Unit, St Vincent's University Hospital, Dublin, Ireland .,School of Medicine, Conway Institute, University College Dublin, Dublin, Ireland
| | - Eoin P Cummins
- School of Medicine, Conway Institute, University College Dublin, Dublin, Ireland
| | - Ramon Farre
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona-IDIBAPS, and CIBER Enfermedades Respiratorias, Barcelona, Spain
| | - Alex Gileles-Hillel
- Pediatric Pulmonology and Sleep Unit, Dept of Pediatrics, and The Wohl Institute for Translational Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Jonathan C Jun
- Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Henrik Oster
- Institute of Neurobiology, University of Lübeck, Lübeck, Germany
| | | | - David W Ray
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK.,Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
| | - Sirimon Reutrakul
- Division of Endocrinology, Diabetes, and Metabolism, Dept of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Manuel Sanchez-de-la-Torre
- Group of Precision Medicine in Chronic Diseases, Hospital Arnau de Vilanova-Santa Maria, IRBLleida, Lleida, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Renaud Tamisier
- HP2 INSERM U1042, Université Grenoble Alpes, Grenoble, France
| | - Isaac Almendros
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona-IDIBAPS, and CIBER Enfermedades Respiratorias, Barcelona, Spain
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19
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Pengo MF, Soranna D, Giontella A, Perger E, Mattaliano P, Schwarz EI, Lombardi C, Bilo G, Zambon A, Steier J, Parati G, Minuz P, Fava C. Obstructive sleep apnoea treatment and blood pressure: which phenotypes predict a response? A systematic review and meta-analysis. Eur Respir J 2020; 55:13993003.01945-2019. [PMID: 32079643 DOI: 10.1183/13993003.01945-2019] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 02/06/2020] [Indexed: 11/05/2022]
Abstract
The treatment for obstructive sleep apnoea (OSA) with continuous positive airway pressure (CPAP) or mandibular advancement devices (MADs) is associated with blood pressure (BP) reduction; however, the overall effect is modest. The aim of this systematic review and meta-analysis of randomised controlled trials (RCTs) comparing the effect of such treatments on BP was to identify subgroups of patients who respond best to treatment.The article search was performed in three different databases with specific search terms and selection criteria. From 2289 articles, we included 68 RCTs that compared CPAP or MADs with either passive or active treatment. When all the studies were pooled together, CPAP and MADs were associated with a mean BP reduction of -2.09 (95% CI -2.78- -1.40) mmHg for systolic BP and -1.92 (95% CI -2.40- -1.43) mmHg for diastolic BP and -1.27 (95% CI -2.34- -0.20) mmHg for systolic BP and -1.11 (95% CI -1.82- -0.41) mmHg for diastolic BP, respectively. The subgroups of patients who showed a greater response were those aged <60 years (systolic BP -2.93 mmHg), with uncontrolled BP at baseline (systolic BP -4.14 mmHg) and with severe oxygen desaturations (minimum arterial oxygen saturation measured by pulse oximetry <77%) at baseline (24-h systolic BP -7.57 mmHg).Although this meta-analysis shows that the expected reduction of BP by CPAP/MADs is modest, it identifies specific characteristics that may predict a pronounced benefit from CPAP in terms of BP control. These findings should be interpreted with caution; however, they are particularly important in identifying potential phenotypes associated with BP reduction in patients treated for OSA.
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Affiliation(s)
- Martino F Pengo
- Dept of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Davide Soranna
- Dept of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy.,These authors are joint co-authors
| | - Alice Giontella
- Section of General Medicine and Hypertension, Dept of Medicine, University of Verona, Verona, Italy.,These authors are joint co-authors
| | - Elisa Perger
- Dept of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Paola Mattaliano
- Dept of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Esther Irene Schwarz
- Dept of Pulmonology and Sleep Disorders Centre, University Hospital of Zurich, Zurich, Switzerland
| | - Carolina Lombardi
- Dept of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Grzegorz Bilo
- Dept of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Antonella Zambon
- Dept of Statistics and Quantitative Methods, Università di Milano-Bicocca, Milan, Italy
| | - Joerg Steier
- CHAPS, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Gianfranco Parati
- Dept of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy.,Dept of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Pietro Minuz
- Section of General Medicine and Hypertension, Dept of Medicine, University of Verona, Verona, Italy
| | - Cristiano Fava
- Section of General Medicine and Hypertension, Dept of Medicine, University of Verona, Verona, Italy
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20
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Zinchuk A, Yaggi HK. Phenotypic Subtypes of OSA: A Challenge and Opportunity for Precision Medicine. Chest 2020; 157:403-420. [PMID: 31539538 PMCID: PMC7005379 DOI: 10.1016/j.chest.2019.09.002] [Citation(s) in RCA: 144] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 08/13/2019] [Accepted: 09/01/2019] [Indexed: 12/21/2022] Open
Abstract
Current strategies for the management of OSA reflect a one-size-fits-all approach. Diagnosis and severity of OSA are based on the apnea-hypopnea index and treatment initiated with CPAP, followed by trials of alternatives (eg, oral appliances) if CPAP "fails." This approach does not consider the heterogeneity of individuals with OSA, reflected by varying risk factors, pathophysiological causes, clinical manifestations, and consequences. Recently, studies using analytic approaches such as cluster analysis have taken advantage of this heterogeneity to identify OSA phenotypes, or subtypes of patients with unique characteristics, that may enable more personalized approaches to prognostication and treatment. Examples include symptom-based subtypes such as "excessively sleepy" and "disturbed sleep" with differing impact of CPAP on symptoms and health-related quality of life. Polysomnographic subtypes, distinguished by respiratory event association with hypoxemia, arousals, or both, exhibit varying risks of cardiovascular disease and response to therapy. This review summarizes the findings from recent cluster analysis studies in sleep apnea and synthesizes common themes to describe the potential role (and limitations) of phenotypic subtypes in precision medicine for OSA. It also highlights future directions, including linking of phenotypes to clinically relevant outcomes, rigorous and transparent assessment of phenotype reproducibility, and need for tools that categorize patients into subtypes, to prospectively validate phenotype-based prognostication and treatment approaches. Finally, we highlight the critical need to include women and more racially/ethnically diverse populations in this area of research if we are to leverage the heterogeneity of OSA to improve patient lives.
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Affiliation(s)
- Andrey Zinchuk
- Department of Internal Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, New Haven, CT.
| | - Henry K Yaggi
- Department of Internal Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, New Haven, CT; Veterans Affairs Connecticut Health Care System, West Haven, CT
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21
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Chen Q, Cheng YB, Shen M, Yin B, Yi HH, Feng J, Li M, Li QY, Li Y, Wang JG. A randomized controlled trial on ambulatory blood pressure lowering effect of CPAP in patients with obstructive sleep apnea and nocturnal hypertension. Blood Press 2019; 29:21-30. [PMID: 31696741 DOI: 10.1080/08037051.2019.1686343] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Objective: In a randomised controlled trial, we investigated the blood pressure (BP) lowering effect of continuous positive airway pressure (CPAP) in patients with moderate-severe obstructive sleep apnoea syndrome (OSAS, an apnoea-hypopnoea index, AHI of 15 or higher) and nocturnal hypertension (night-time systolic/diastolic BP ≥120/70 mmHg).Methods: Sixty patients were randomly assigned to CPAP or sham CPAP, while maintaining their antihypertensive treatment. Ambulatory BP monitoring was performed at baseline (first run-in visit) and the end of follow-up. Clinic and home BP were measured at baseline and each of the monthly follow-up visits.Results: Of the 60 patients, 47 completed the 3-month study. CPAP (n = 26), compared with sham CPAP (n = 21), slightly and non-significantly reduced 24-h systolic/diastolic BP by -2.8/-2.5 mmHg (p ≥ 0.27), with a slightly greater between-group difference in the daytime (-4.0/-2.8 mmHg, p ≥ 0.29) than night-time (-0.2/-1.5 mmHg, p ≥ 0.50). The CPAP treatment did not significantly influence clinic or home BP during follow-up (p ≥ 0.27). Nonetheless, simple and partial correlation analyses showed that the ambulatory BP lowering effect was dependent on the daytime pulse rate at baseline (r ≥ 0.47, p ≤ 0.01). In patients with a daytime pulse rate greater than 85 beats/min, the mean changes in daytime systolic BP were significantly greater in the CPAP (n = 10) than sham CPAP group (n = 11), with a between-group mean difference of -10.1 mmHg (p = 0.048).Conclusions: The CPAP treatment did not show significant ambulatory BP lowering effect in patients with moderate-severe OSAS and nocturnal hypertension. However, it may be effective in lowering daytime BP in patients with a faster pulse rate.
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Affiliation(s)
- Qi Chen
- Centre for Epidemiological Studies and Clinical Trials, Shanghai Key Laboratory of Hypertension, the Shanghai Institute of Hypertension, Department of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yi-Bang Cheng
- Centre for Epidemiological Studies and Clinical Trials, Shanghai Key Laboratory of Hypertension, the Shanghai Institute of Hypertension, Department of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Meng Shen
- Health Systems, Philips Research China, Shanghai, China
| | - Bin Yin
- Health Systems, Philips Research China, Shanghai, China
| | - Hua-Hua Yi
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jing Feng
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Min Li
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Qing-Yun Li
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yan Li
- Centre for Epidemiological Studies and Clinical Trials, Shanghai Key Laboratory of Hypertension, the Shanghai Institute of Hypertension, Department of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ji-Guang Wang
- Centre for Epidemiological Studies and Clinical Trials, Shanghai Key Laboratory of Hypertension, the Shanghai Institute of Hypertension, Department of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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22
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Prasad B, Sánchez-de-la-Torre M. The association of sleep disturbances measures with blood pressure: is the time to explore novel measurements? Thorax 2019; 75:4-5. [PMID: 31678971 DOI: 10.1136/thoraxjnl-2019-213953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2019] [Indexed: 11/03/2022]
Affiliation(s)
- Bharati Prasad
- Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Manuel Sánchez-de-la-Torre
- Group of Precision Medicine in Chronic Diseases, Hospital Arnau de Vilanova-Santa Maria, IRB Lleida, Lleida, Spain .,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
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23
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Kuna ST, Townsend RR, Keenan BT, Maislin D, Gislason T, Benediktsdóttir B, Gudmundsdóttir S, Arnardóttir ES, Sifferman A, Staley B, Pack FM, Guo X, Schwab RJ, Maislin G, Chirinos JA, Pack AI. Blood pressure response to treatment of obese vs non-obese adults with sleep apnea. J Clin Hypertens (Greenwich) 2019; 21:1580-1590. [PMID: 31532580 DOI: 10.1111/jch.13689] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 07/13/2019] [Accepted: 07/22/2019] [Indexed: 12/11/2022]
Abstract
Many patients with obstructive sleep apnea (OSA), but not all, have a reduction in blood pressure (BP) with positive airway pressure (PAP) treatment. Our objective was to determine whether the BP response following PAP treatment is related to obesity. A total of 188 adults with OSA underwent 24-hour BP monitoring and 24-hour urinary norepinephrine collection at baseline. Obesity was assessed by waist circumference, body mass index, and abdominal visceral fat volume. Participants adherent to PAP treatment were reassessed after 4 months. Primary outcomes were 24-hour mean arterial pressure (MAP) and 24-hour urinary norepinephrine level. Obstructive sleep apnea participants had a significant reduction in 24-hour MAP following PAP treatment (-1.22 [95% CI: -2.38, -0.06] mm Hg; P = .039). No significant correlations were present with any of the 3 obesity measures for BP or urinary norepinephrine measures at baseline in all OSA participants or for changes in BP measures in participants adherent to PAP treatment. Changes in BP measures following treatment were not correlated with baseline or change in urinary norepinephrine. Similar results were obtained when BP or urinary norepinephrine measures were compared between participants dichotomized using the sex-specific median of each obesity measure. Greater reductions in urinary norepinephrine were correlated with higher waist circumference (rho = -0.21, P = .037), with a greater decrease from baseline in obese compared to non-obese participants (-6.26 [-8.82, -3.69] vs -2.14 [-4.63, 0.35] ng/mg creatinine; P = .027). The results indicate that the BP response to PAP treatment in adults with OSA is not related to obesity or urinary norepinephrine levels.
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Affiliation(s)
- Samuel T Kuna
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Center for Sleep and Circadian Neurobiology, University of Pennsylvania, Philadelphia, PA, USA.,Sleep Medicine Section, Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Raymond R Townsend
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Brendan T Keenan
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Center for Sleep and Circadian Neurobiology, University of Pennsylvania, Philadelphia, PA, USA
| | - David Maislin
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Center for Sleep and Circadian Neurobiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Thorarinn Gislason
- Sleep Department, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Bryndís Benediktsdóttir
- Sleep Department, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Sigrun Gudmundsdóttir
- Sleep Department, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
| | - Erna Sif Arnardóttir
- School of Science and Engineering, Reykjavik University, Reykjavik, Iceland.,Internal Medicine Services, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
| | - Andrea Sifferman
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Center for Sleep and Circadian Neurobiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Beth Staley
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Center for Sleep and Circadian Neurobiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Frances M Pack
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Center for Sleep and Circadian Neurobiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Xiaofeng Guo
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Richard J Schwab
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Center for Sleep and Circadian Neurobiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Greg Maislin
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania, Philadelphia, PA, USA.,Biomedical Statistical Consulting, Wynnewood, PA, USA
| | - Julio A Chirinos
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Cardiovascular Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Allan I Pack
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Center for Sleep and Circadian Neurobiology, University of Pennsylvania, Philadelphia, PA, USA
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Edwards BA, Redline S, Sands SA, Owens RL. More Than the Sum of the Respiratory Events: Personalized Medicine Approaches for Obstructive Sleep Apnea. Am J Respir Crit Care Med 2019; 200:691-703. [PMID: 31022356 PMCID: PMC6775874 DOI: 10.1164/rccm.201901-0014tr] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 04/22/2019] [Indexed: 11/16/2022] Open
Abstract
Traditionally, the presence and severity of obstructive sleep apnea (OSA) have been defined by the apnea-hypopnea index (AHI). Continuous positive airway pressure is generally first-line therapy despite low adherence, because it reliably reduces the AHI when used, and the response to other therapies is variable. However, there is growing appreciation that the underlying etiology (i.e., endotype) and clinical manifestation (i.e., phenotype) of OSA in an individual are not well described by the AHI. We define and review the important progress made in understanding and measuring physiological mechanisms (or endotypes) that help define subtypes of OSA and identify the potential use of genetics to further refine disease classification. This more detailed understanding of OSA pathogenesis should influence clinical treatment decisions as well as help inform research priorities and clinical study design. In short, treatments could be individualized on the basis of the underlying cause of OSA; patients could better understand which symptoms and outcomes will respond to OSA treatment and by how much; and researchers could select populations most likely to benefit from specific treatment approaches for OSA.
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Affiliation(s)
- Bradley A. Edwards
- Sleep and Circadian Medicine Laboratory, Department of Physiology, and
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
- Division of Sleep and Circadian Disorders, Department of Medicine and Department of Neurology, Brigham & Women’s Hospital and Harvard Medical School, Boston, Massachusetts; and
| | - Susan Redline
- Division of Sleep and Circadian Disorders, Department of Medicine and Department of Neurology, Brigham & Women’s Hospital and Harvard Medical School, Boston, Massachusetts; and
| | - Scott A. Sands
- Division of Sleep and Circadian Disorders, Department of Medicine and Department of Neurology, Brigham & Women’s Hospital and Harvard Medical School, Boston, Massachusetts; and
| | - Robert L. Owens
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, La Jolla, California
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25
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Cistulli PA, Sutherland K. Phenotyping obstructive sleep apnoea—Bringing precision to oral appliance therapy. J Oral Rehabil 2019; 46:1185-1191. [DOI: 10.1111/joor.12857] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/04/2019] [Accepted: 07/04/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Peter A. Cistulli
- Sleep Research Group, Charles Perkins Centre, Faculty of Medicine and Health University of Sydney Sydney New South Wales Australia
- Centre for Sleep Health and Research, Department of Respiratory and Sleep Medicine Royal North Shore Hospital Sydney New South Wales Australia
| | - Kate Sutherland
- Sleep Research Group, Charles Perkins Centre, Faculty of Medicine and Health University of Sydney Sydney New South Wales Australia
- Centre for Sleep Health and Research, Department of Respiratory and Sleep Medicine Royal North Shore Hospital Sydney New South Wales Australia
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26
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Sapiña-Beltrán E, Torres G, Benítez I, Santamaría-Martos F, Durán-Cantolla J, Egea C, Sánchez-de-la-Torre M, Barbé F, Dalmases M. Differential blood pressure response to continuous positive airway pressure treatment according to the circadian pattern in hypertensive patients with obstructive sleep apnoea. Eur Respir J 2019; 54:13993003.00098-2019. [PMID: 31097515 DOI: 10.1183/13993003.00098-2019] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 04/21/2019] [Indexed: 01/08/2023]
Abstract
Continuous positive airway pressure (CPAP) has a heterogeneous effect on blood pressure (BP) in hypertensive patients. However, the effect of CPAP on BP in hypertensive subjects regarding circadian BP pattern has never been explored. This study aimed to assess the effect of CPAP on BP, taking into consideration the circadian BP pattern in untreated hypertensive patients.This study is a post hoc analysis of the Spanish Cohort for the Study of the Effect of CPAP in Hypertension (CEPECTA), a multicentre, randomised trial of CPAP versus sham-CPAP in patients with new-onset systemic hypertension and an apnoea-hypopnoea index >15 events·h-1 We included patients for whom 24-h ambulatory BP monitoring (ABPM) data were available at baseline and 12 weeks after the intervention. Subjects were classified based on the dipping ratio (dipper/non-dipper). We evaluated the effect of CPAP on ABPM parameters after 12 weeks of treatment.Overall, 272 hypertensive subjects were included in the analysis (113 dippers and 159 non-dippers). Baseline clinical and polysomnographic variables were similar between the groups. CPAP treatment in non-dipper patients was associated with reductions in 24-h ambulatory BP variables and night-time ambulatory BP measurements. However, a nonsignificant effect was reported in the dipper group. The differential effects of CPAP between the groups were -2.99 mmHg (95% CI -5.92-- -0.06 mmHg) for the mean 24-h ambulatory BP and -5.35 mmHg (95% CI -9.01- -1.69 mmHg) for the mean night-time ambulatory BP.Our results show a differential effect of CPAP treatment on BP in hypertensive patients depending on the circadian pattern. Only non-dipper patients benefited from CPAP treatment in terms of BP reduction.
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Affiliation(s)
- Esther Sapiña-Beltrán
- Hospital Universitari Arnau de Vilanova and Santa Maria, Group of Translational Research in Respiratory Medicine, IRB Lleida, Universitat de Lleida, Lleida, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Gerard Torres
- Hospital Universitari Arnau de Vilanova and Santa Maria, Group of Translational Research in Respiratory Medicine, IRB Lleida, Universitat de Lleida, Lleida, Spain
| | - Iván Benítez
- Hospital Universitari Arnau de Vilanova and Santa Maria, Group of Translational Research in Respiratory Medicine, IRB Lleida, Universitat de Lleida, Lleida, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Fernando Santamaría-Martos
- Hospital Universitari Arnau de Vilanova and Santa Maria, Group of Translational Research in Respiratory Medicine, IRB Lleida, Universitat de Lleida, Lleida, Spain
| | - Joaquín Durán-Cantolla
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Bioaraba Research Institute, OSI Araba University Hospital, Dept of Medicine of Basque Country University, Vitoria-Gasteiz, Spain
| | - Carlos Egea
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Unidad Funcional de Sueño, Bioaraba Research Institute, OSI Araba University Hospital, Dept of Medicine of Basque Country University, Vitoria-Gasteiz, Spain
| | - Manuel Sánchez-de-la-Torre
- Hospital Universitari Arnau de Vilanova and Santa Maria, Group of Translational Research in Respiratory Medicine, IRB Lleida, Universitat de Lleida, Lleida, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Ferrán Barbé
- Hospital Universitari Arnau de Vilanova and Santa Maria, Group of Translational Research in Respiratory Medicine, IRB Lleida, Universitat de Lleida, Lleida, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Mireia Dalmases
- Hospital Universitari Arnau de Vilanova and Santa Maria, Group of Translational Research in Respiratory Medicine, IRB Lleida, Universitat de Lleida, Lleida, Spain .,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
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Marrone O, Bonsignore MR. Decrease in blood pressure during continuous positive airway pressure treatment for obstructive sleep apnoea: still searching for predictive factors. Eur Respir J 2019; 54:54/1/1901219. [DOI: 10.1183/13993003.01219-2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 06/20/2019] [Indexed: 12/21/2022]
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28
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Ren L, Wang K, Shen H, Xu Y, Wang J, Chen R. Effects of continuous positive airway pressure (CPAP) therapy on neurological and functional rehabilitation in Basal Ganglia Stroke patients with obstructive sleep apnea: A prospective multicenter study. Medicine (Baltimore) 2019; 98:e16344. [PMID: 31305423 PMCID: PMC6641828 DOI: 10.1097/md.0000000000016344] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Obstructive sleep apnea (OSA) adversely affects neurological recovery. This study aimed to determine the impact of continuous positive airway pressure (CPAP) and/or rehabilitation in basal ganglia stroke patients with OSA.A prospective controlled trial was conducted in 2015-2018. The subjects received routine rehabilitation training for up to 2 years and were assigned to the intervention and control groups treated with CPAP or without, respectively. Then, treatment effects on sleep parameters, motor function, stroke severity, daily life activities, cognitive function, and psychological states were assessed at different time points.At 6 months, the CPAP group showed significantly lower mean apnea-hypopnea index (AHI), percentage of time with SpO2 at <90% (TS90%), micro-arousal index, and percentages of time in non-rapid eye movement (non-REM) stages 1-2 and REM stage in total sleeping time compared with the control group, and significantly higher mean minimum of peripheral oxygen saturation (L-SaO2%) and percentage of time in stage 3 (P < .001) sleep. The CPAP group showed significant improvements in average the National Institutes of Health Stroke Scale (NIHSS), Fugl-Meyer assessment scale (FMA), Barthel index (BI), Minimental state examination (MMSE), Hamilton anxiety scale (HAMA) and Hamilton depression rating scale for depression (HRSD) scores at different times versus the control group, respectively (P < .05). However, no difference in body mass index (BMI) management was observed (P > .05). Repeated-measures ANOVA revealed significant interactions between the two groups for change in FMA, MMSE, BI, HAMA, and HRSD scores from admission to 24 months (P < .001), but no significant was found for BMI (P = .582).Basal ganglia stroke patients with OSA tend to have significantly greater sleeping, neurological and functional recovery after CPAP, and rehabilitation over 2 years.
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Affiliation(s)
- Lei Ren
- Department of Respiratory Medicine, The Second Affiliated Hospital of Suzhou University, Suzhou, Jiangsu
- Department of Respiratory Rehabilitation, The Fourth Rehabilitation Hospital of Shanghai (Shanghai Jingan Geriatric Hospital)
| | - Kai Wang
- Department of Neurological Rehabilitation, The Fourth Rehabilitation Hospital of Shanghai (Shanghai Jingan Geriatric Hospital), Shanghai, China
| | - Honghua Shen
- Department of Respiratory Rehabilitation, The Fourth Rehabilitation Hospital of Shanghai (Shanghai Jingan Geriatric Hospital)
| | - Yiming Xu
- Department of Respiratory Rehabilitation, The Fourth Rehabilitation Hospital of Shanghai (Shanghai Jingan Geriatric Hospital)
| | - Jing Wang
- Department of Respiratory Medicine, The Second Affiliated Hospital of Suzhou University, Suzhou, Jiangsu
| | - Rui Chen
- Department of Respiratory Medicine, The Second Affiliated Hospital of Suzhou University, Suzhou, Jiangsu
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Drager LF, Lorenzi-Filho G. POINT: Should Sleep Studies Be Performed for All Patients With Poorly Controlled Hypertension? Yes. Chest 2019; 155:1095-1097. [DOI: 10.1016/j.chest.2019.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 04/04/2019] [Indexed: 01/20/2023] Open
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30
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Rebuttal From Drs Drager and Lorenzi-Filho. Chest 2019; 155:1101-1102. [DOI: 10.1016/j.chest.2019.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 04/04/2019] [Indexed: 11/19/2022] Open
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31
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Parati G, Pengo MF, Lombardi C. Obstructive Sleep Apnea and Hypertension: Why Treatment Does Not Consistently Improve Blood Pressure. Curr Hypertens Rep 2019; 21:30. [PMID: 30949909 DOI: 10.1007/s11906-019-0935-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Obstructive sleep apnea (OSA) and hypertension are two phenomena deeply linked together and, although a causal relationship has been suggested, a recent meta-analysis showed only a very modest effect of OSA treatment on blood pressure (BP). However, a vast number of randomized controlled trials published so far share some limitations, mainly of methodological nature: neither OSA nor BP is always assessed in a standardized way. Moreover, compliance with OSA treatment is often sub-optimal making the results of these trials difficult to interpret. RECENT FINDINGS Recent studies have shown that antihypertensive drugs can reduce BP more than OSA treatment, showing a better compliance profile and very few side effects. Considering the importance of reducing the overall cardiovascular risk of OSA patients, a more careful management of patient's antihypertensive medication could allow a better BP control also in this condition. In addition, greater efforts should be made to improve patient's acceptance of OSA treatment with the aim of improving their compliance.
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Affiliation(s)
- Gianfranco Parati
- Sleep Disorder Centre, Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Ospedale San Luca, Via Magnasco, 2, Milan, Italy. .,Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.
| | - Martino Francesco Pengo
- Sleep Disorder Centre, Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Ospedale San Luca, Via Magnasco, 2, Milan, Italy
| | - Carolina Lombardi
- Sleep Disorder Centre, Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Ospedale San Luca, Via Magnasco, 2, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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32
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Sapiña-Beltrán E, Santamaria-Martos F, Benítez I, Torres G, Masa JF, Sánchez-de-la-Torre M, Barbé F, Dalmases M. Normotensive patients with obstructive sleep apnoea: changes in 24-h ambulatory blood pressure monitoring with continuous positive airway pressure treatment. J Hypertens 2019; 37:720-727. [PMID: 30817452 DOI: 10.1097/hjh.0000000000001934] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Continuous positive airway pressure (CPAP) treatment reduces blood pressure (BP) in obstructive sleep apnoea (OSA) and hypertensive patients, but there is a lack of data about the effects of CPAP on the BP in normotensive patients. OBJECTIVE The aim of the study was to evaluate BP changes in normotensive OSA individuals receiving CPAP treatment. METHODS We selected 131 normotensive outpatients with an apnoea/hypopnoea index (AHI) greater than 15 events/hour who required CPAP treatment. All patients underwent a sleep study and 24-h ambulatory BP monitoring (ABPM) at baseline and after 6 months. In addition, the patients were assessed for the presence of baseline masked hypertension, defined as office BP less than 140/90 mmHg and increased BP on 24-h ABPM (mean 24-h BP ≥130/80 mmHg). RESULTS After 6 months of CPAP treatment, a mild reduction in all 24-h ABPM variables was observed, but only the mean 24-h DBP [-1.39 mmHg, 95% confidence interval (95% CI), -2.50 to -0.27], mean daytime DBP (-1.39 mmHg, 95% CI -2.56 to -0.22) and the mean 24-h ambulatory BP (-1.80 mmHg, 95% CI, -3.16 to -0.44) reached statistical significance. The reduction was primarily due to BP changes in individuals with masked hypertension who displayed a mean BP reduction of -4.78 mmHg (-7.25 to -2.30 mmHg). Consistent with a circadian BP pattern, a reduction in mean nocturnal BP of -4.73 mmHg (-7.39 to -2.06 mmHg) was observed at 6 months in nondippers; in contrast, the mean nocturnal BP in dippers increased by 2.61 mmHg (0.60-4.62 mmHg). CONCLUSION Our findings suggest that the CPAP effects may be different in normotensive outpatients depending on the presence of undiagnosed masked hypertension and the dipping pattern. Therefore, it is important to consider measuring ABPM in this type of patient.
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Affiliation(s)
- Esther Sapiña-Beltrán
- Group of Translational Research in Respiratory Medicine, Hospital Universitari Arnau de Vilanova and Santa Maria, IRBLleida, UdL, Lleida
| | - Fernando Santamaria-Martos
- Group of Translational Research in Respiratory Medicine, Hospital Universitari Arnau de Vilanova and Santa Maria, IRBLleida, UdL, Lleida
| | - Ivan Benítez
- Group of Translational Research in Respiratory Medicine, Hospital Universitari Arnau de Vilanova and Santa Maria, IRBLleida, UdL, Lleida
| | - Gerard Torres
- Group of Translational Research in Respiratory Medicine, Hospital Universitari Arnau de Vilanova and Santa Maria, IRBLleida, UdL, Lleida
| | - Juan F Masa
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid
- Hospital San Pedro de Alcántara, Cáceres, Spain
| | - Manuel Sánchez-de-la-Torre
- Group of Translational Research in Respiratory Medicine, Hospital Universitari Arnau de Vilanova and Santa Maria, IRBLleida, UdL, Lleida
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid
| | - Ferran Barbé
- Group of Translational Research in Respiratory Medicine, Hospital Universitari Arnau de Vilanova and Santa Maria, IRBLleida, UdL, Lleida
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid
| | - Mireia Dalmases
- Group of Translational Research in Respiratory Medicine, Hospital Universitari Arnau de Vilanova and Santa Maria, IRBLleida, UdL, Lleida
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid
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Javaheri S, Reid M, Drerup M, Mehra R, Redline S. Reducing Coronary Heart Disease Risk Through Treatment of Insomnia Using Web-Based Cognitive Behavioral Therapy for Insomnia: A Methodological Approach. Behav Sleep Med 2019; 18:334-344. [PMID: 30829067 PMCID: PMC6722027 DOI: 10.1080/15402002.2019.1584896] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objective: Observational data demonstrate increased risk of recurrent acute coronary syndrome in patients with comorbid insomnia. We conducted a pragmatic randomized controlled pilot study to address knowledge gaps and inform future large-scale randomized trials to test the impact of Web-based cognitive behavioral therapy for insomnia (wCBT-I) on coronary heart disease (CHD) outcomes. Participants: Thirty-five adults recruited from Brigham and Women's and Cleveland Clinic Hospitals with insomnia, defined by Insomnia Severity Index (ISI) score ≥ 10 and symptoms of at least 3 months, and comorbid CHD identified from medical records. Methods: We randomized 34 patients to either general sleep education coupled with wCBT-I or general sleep education alone followed by an opportunity for treatment after the study (a wait-list control) to evaluate feasibility and uptake of insomnia treatment in patients with heart disease. Participants completed the ISI at baseline and 6 weeks to assess insomnia severity. Results: Twenty-nine adults completed the trial, yielding an 85% retention rate, and adherence rate in the treatment arm was 80%. Mean age was 71.6 ± 9.5 years, 75% were male, and mean body mass index (BMI) was 29 ± 4.5 kg/m2. Baseline ISI scores were 15.6. There was a 6.2 ± 5.3 point reduction in ISI scores in the intervention arm and a 3.3 ± 5.1 reduction in the control arm (p value 0.1). Conclusion: Web-based CBT-I intervention was feasible in an older sample with prevalent CHD and resulted in clinically meaningful improvement in insomnia severity, though statistical significance was limited by lack of power.
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Affiliation(s)
- Sogol Javaheri
- Brigham and Women’s Hospital, Boston and Harvard Medical School, Boston, MA
| | | | | | - Reena Mehra
- Cleveland Clinic Sleep Disorders Center, Cleveland, OH
| | - Susan Redline
- Brigham and Women’s Hospital, Boston and Harvard Medical School, Boston, MA,Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
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34
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McNicholas WT. Obstructive sleep apnoea and comorbidity - an overview of the association and impact of continuous positive airway pressure therapy. Expert Rev Respir Med 2019; 13:251-261. [PMID: 30691323 DOI: 10.1080/17476348.2019.1575204] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Obstructive sleep apnoea (OSA) is highly prevalent and there is considerable evidence supporting an independent association with a wide range of co-morbidities including cardiovascular, endocrine and metabolic, neuropsychiatric, pulmonary, and renal. Areas covered: A PubMed search of all the recent literature relating to OSA and co-morbidities was undertaken to critically evaluate the potential relationships and possible benefit of continuous positive airway pressure (CPAP) therapy. Expert commentary: The evidence supporting an independent association is stronger for some co-morbidities than others and in cardiovascular diseases is strongest for hypertension and atrial fibrillation. Potential mechanisms include intermittent hypoxia, fluctuating intrathoracic pressure, and recurring micro-arousals that trigger cell and molecular consequences including sympathetic excitation, systemic inflammation and oxidative stress, in addition to metabolic and endothelial dysfunction. Different mechanisms may predominate in individual co-morbidities. Recent long term randomised controlled trials have cast doubt on benefits to co-morbidities from CPAP therapy of OSA, especially where co-morbidities are already established. However, benefits may result in patients who are compliant with therapy and further research is required to clearly establish the role of OSA therapy in both primary and secondary prevention of co-morbidities.
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Affiliation(s)
- Walter T McNicholas
- a Department of Respiratory and Sleep Medicine, St. Vincent's Hospital Group and School of Medicine , University College Dublin , Dublin , Ireland.,b First Affiliated Hospital of Guangzhou Medical University , Guangzhou , China
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35
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Sutherland K, Kairaitis K, Yee BJ, Cistulli PA. From CPAP to tailored therapy for obstructive sleep Apnoea. Multidiscip Respir Med 2018; 13:44. [PMID: 30524729 PMCID: PMC6276208 DOI: 10.1186/s40248-018-0157-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 10/30/2018] [Indexed: 12/20/2022] Open
Abstract
Obstructive Sleep Apnoea (OSA) is a common sleep disorder that is associated with daytime symptoms and a range of comorbidity and mortality. Continuous Positive Airway Pressure (CPAP) therapy is highly efficacious at preventing OSA when in use and has long been the standard treatment for newly diagnosed patients. However, CPAP therapy has well recognised limitations in real world effectiveness due to issues with patient acceptance and suboptimal usage. There is a clear need to enhance OSA treatment strategies and options. Although there are a range of alternative treatments (e.g. weight loss, oral appliances, positional devices, surgery, and emerging therapies such as sedatives and oxygen), generally there are individual differences in efficacy and often OSA will not be completely eliminated. There is increasing recognition that OSA is a heterogeneous disorder in terms of risk factors, clinical presentation, pathophysiology and comorbidity. Better characterisation of OSA heterogeneity will enable tailored approaches to therapy to ensure treatment effectiveness. Tools to elucidate individual anatomical and pathophysiological phenotypes in clinical practice are receiving attention. Additionally, recognising patient preferences, treatment enhancement strategies and broader assessment of treatment effectiveness are part of tailoring therapy at the individual level. This review provides a narrative of current treatment approaches and limitations and the future potential for individual tailoring to enhance treatment effectiveness.
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Affiliation(s)
- Kate Sutherland
- 1Charles Perkins Centre, The University of Sydney, Sydney, Australia.,2Faculty of Medicine & Health, The University of Sydney School of Medicine, Sydney, Australia.,3Centre for Sleep Health & Research, Department of Respiratory Medicine, Royal North Shore Hospital, Northern Sydney Local Health District, Sydney, Australia
| | - Kristina Kairaitis
- 1Charles Perkins Centre, The University of Sydney, Sydney, Australia.,2Faculty of Medicine & Health, The University of Sydney School of Medicine, Sydney, Australia.,4Ludwig Engel Centre for Respiratory Research, Westmead Institute for Medical Research, University of Sydney, Sydney, Australia.,5Department of Respiratory and Sleep Medicine, Westmead Hospital, Sydney, Australia
| | - Brendon J Yee
- 2Faculty of Medicine & Health, The University of Sydney School of Medicine, Sydney, Australia.,6NHMRC Centre for Integrated Research and Understanding of Sleep (CIRUS) and NHMRC NeuroSleep Centre Woolcock Institute of Medical Research, Sydney, Australia.,7Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, Australia
| | - Peter A Cistulli
- 1Charles Perkins Centre, The University of Sydney, Sydney, Australia.,2Faculty of Medicine & Health, The University of Sydney School of Medicine, Sydney, Australia.,3Centre for Sleep Health & Research, Department of Respiratory Medicine, Royal North Shore Hospital, Northern Sydney Local Health District, Sydney, Australia
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36
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Abstract
There is consistent epidemiological evidence that sleep disordered breathing and systemic arterial hypertension are deeply associated, being linked through a bidirectional complex interaction among multiple mechanisms including autonomic nervous system alterations, inflammation, hormonal and hemodynamic components, sleep alterations. However there are several unanswered questions not only from a pathophysiological perspective, but also regarding the effects of obstructive sleep apnea (OSA) treatment on arterial blood pressure values. At present, while many studies have supported the possibility to obtain at least a small blood pressure reduction with OSA treatment, in particular in hypertensive patients, large trials have not clearly confirmed a significant anti-hypertensive effect, nor a beneficial effect of this intervention on cardiovascular endpoints including cardiovascular mortality. Aim of the present review article is to address the relationship between OSA and hypertension in the light of the latest evidence in the field. Moreover we will discuss research topics which need to be investigated in the future, in order to better clarify still pending issues with the aim of obtaining an early diagnosis, a more suitable phenotyping including comorbidities, and better strategies to improve patients' compliance and adherence to treatment.
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Affiliation(s)
- Carolina Lombardi
- Istituto Auxologico Italiano, IRCCS, Dipartimento di Scienze Cardiovascolari, Neurologiche e Metaboliche, S.Luca Hospital, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Martino F Pengo
- Istituto Auxologico Italiano, IRCCS, Dipartimento di Scienze Cardiovascolari, Neurologiche e Metaboliche, S.Luca Hospital, Milan, Italy
| | - Gianfranco Parati
- Istituto Auxologico Italiano, IRCCS, Dipartimento di Scienze Cardiovascolari, Neurologiche e Metaboliche, S.Luca Hospital, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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37
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Genta-Pereira DC, Furlan SF, Omote DQ, Giorgi DM, Bortolotto LA, Lorenzi-Filho G, Drager LF. Nondipping Blood Pressure Patterns Predict Obstructive Sleep Apnea in Patients Undergoing Ambulatory Blood Pressure Monitoring. Hypertension 2018; 72:979-985. [DOI: 10.1161/hypertensionaha.118.11525] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A nondipping blood pressure (BP) pattern is common in patients with obstructive sleep apnea (OSA). However, it is unclear how useful a nondipping BP pattern is in screening for OSA. In this cross-sectional study, we recruited consecutive patients with clinical indications for performing ambulatory BP monitoring evaluating the following dipping patterns: (1) normal: ≥10% but <20%; (2) extreme: ≥20%; (3) reduced: ≥0% but <10%; and (4) reverse (riser): <0%. Sleep questionnaires and sleep studies were performed within 7 days after ambulatory BP monitoring. OSA was defined as an apnea-hypopnea index ≥15 events/h. We evaluated 153 patients (OSA frequency, 50.3%). Patients with OSA had higher BPs during sleep, were taking more antihypertensive drugs, and more frequently used hypertensive drugs during the night than patients without OSA. Considering systolic BP, the frequency of OSA in patients with reverse dippers (73.5%) was higher than normal (37.3%), extreme (46.2%), and reduced dippers (49.1%;
P
=0.012). For diastolic BP, OSA was more common in reduced (66.7%) and reverse dippers (69.6%) as compared to normal (41.4%) or extreme dippers (33.3%;
P
=0.007). In the regression analysis, reverse systolic dipper was independently associated with OSA (odds ratio, 3.92; 95% CI, 1.31–11.78). Both reduced and reverse diastolic dippers increased the likelihood of OSA for 2.7-fold and 3.5-fold, respectively. Snoring and positive sleep questionnaire findings were associated with a modest increase in the accuracy of reverse dipping pattern for predicting OSA. In conclusion, reverse systolic, as well as reduced and reverse diastolic dippers are independently associated with OSA.
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Affiliation(s)
- Daniel Castanho Genta-Pereira
- From the Program in Cardiology, Faculty of Medicine, University of São Paulo, Brazil (D.C.G.-P., S.F.F.)
- Hypertension Unit, Heart Institute (InCor) (D.C.G.-P., S.F.F., D.Q.O., D.M.A.G., L.A.B., L.F.D.), University of São Paulo Medical School, Brazil
| | - Sofia F. Furlan
- From the Program in Cardiology, Faculty of Medicine, University of São Paulo, Brazil (D.C.G.-P., S.F.F.)
- Hypertension Unit, Heart Institute (InCor) (D.C.G.-P., S.F.F., D.Q.O., D.M.A.G., L.A.B., L.F.D.), University of São Paulo Medical School, Brazil
| | - Daniel Q. Omote
- Hypertension Unit, Heart Institute (InCor) (D.C.G.-P., S.F.F., D.Q.O., D.M.A.G., L.A.B., L.F.D.), University of São Paulo Medical School, Brazil
| | - Dante M.A. Giorgi
- Hypertension Unit, Heart Institute (InCor) (D.C.G.-P., S.F.F., D.Q.O., D.M.A.G., L.A.B., L.F.D.), University of São Paulo Medical School, Brazil
| | - Luiz A. Bortolotto
- Hypertension Unit, Heart Institute (InCor) (D.C.G.-P., S.F.F., D.Q.O., D.M.A.G., L.A.B., L.F.D.), University of São Paulo Medical School, Brazil
| | - Geraldo Lorenzi-Filho
- Sleep Laboratory, Pulmonary Division (G.L.-F.), University of São Paulo Medical School, Brazil
| | - Luciano F. Drager
- Hypertension Unit, Heart Institute (InCor) (D.C.G.-P., S.F.F., D.Q.O., D.M.A.G., L.A.B., L.F.D.), University of São Paulo Medical School, Brazil
- Hypertension Unit, Renal Division (L.F.D.), University of São Paulo Medical School, Brazil
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38
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Tamisier R, Weiss JW, Pépin JL. Sleep biology updates: Hemodynamic and autonomic control in sleep disorders. Metabolism 2018; 84:3-10. [PMID: 29572132 DOI: 10.1016/j.metabol.2018.03.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 03/13/2018] [Accepted: 03/14/2018] [Indexed: 02/07/2023]
Abstract
Sleep disorders like obstructive sleep apnea syndrome, periodic limb movements in sleep syndrome, insomnia and narcolepsy-cataplexy are all associated with an increased risk of cardiovascular diseases. These disorders share an impaired autonomic nervous system regulation that leads to increased cardiovascular sympathetic tone. This increased cardiovascular sympathetic tone is, in turn, likely to play a major role in the increased risk of cardiovascular disease. Different stimuli, such as intermittent hypoxia, sleep fragmentation, decrease in sleep duration, increased respiratory effort, and transient hypercapnia may all initiate the pathophysiological cascade leading to sympathetic overactivity and some or all of these are encountered in these different sleep disorders. In this manuscript, we outline the different pathways leading to sympathetic over-activity in different sleep conditions. This augmented sympathetic tone is likely to play an important role in the development of cardiovascular disease in patients with sleep disorders, and it is further hypothesized to that sympathoexcitation contributes to the metabolic dysregulation associated with these sleep disorders.
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Affiliation(s)
- Renaud Tamisier
- University Grenoble Alpes, HP2, Inserm 1042, Grenoble F-38042, France; Physiology Sleep and Exercise Clinic, Thorax and Vessel division, Grenoble Alpes hospital, Grenoble 38043, France.
| | - J Woodrow Weiss
- Pulmonary Physiology Laboratory, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, United States
| | - Jean Louis Pépin
- University Grenoble Alpes, HP2, Inserm 1042, Grenoble F-38042, France; Physiology Sleep and Exercise Clinic, Thorax and Vessel division, Grenoble Alpes hospital, Grenoble 38043, France
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39
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Bhattacharjee R, Khalyfa A, Khalyfa AA, Mokhlesi B, Kheirandish-Gozal L, Almendros I, Peris E, Malhotra A, Gozal D. Exosomal Cargo Properties, Endothelial Function and Treatment of Obesity Hypoventilation Syndrome: A Proof of Concept Study. J Clin Sleep Med 2018; 14:797-807. [PMID: 29734990 DOI: 10.5664/jcsm.7110] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 02/09/2018] [Indexed: 01/19/2023]
Abstract
STUDY OBJECTIVES Longitudinal studies support the usage of positive airway pressure (PAP) therapy in treating obstructive sleep apnea (OSA) to improve cardiovascular disease. However, the anticipated benefit is not ubiquitous. In this study, we elucidate whether PAP therapy leads to immediate improvements on endothelial function, a subclinical marker of cardiovascular status, by examining the effect of circulating exosomes, isolated from patients before and after PAP therapy, on naive endothelial cells. METHODS We isolated plasma-derived circulating exosomes from 12 patients with severe OSA and obesity hypoventilation syndrome (OHS) before and after 6 weeks of PAP therapy, and examined their effect on cultured endothelial cells using several in vitro reporter assays. RESULTS We found that circulating exosomes contributed to the induction and propagation of OSA/OHS-related endothelial dysfunction (ie, increased permeability and disruption of tight junctions along with increased adhesion molecule expression, and reduced endothelial nitric oxide synthase expression), and promoted increased monocyte adherence. Further, when comparing exosomes isolated before and after PAP therapy, the disturbances in endothelial cell function were attenuated with treatment, including an overall cumulative decrease in endothelial permeability in all 12 subjects by 10.8% (P = .035), as well as detection of a subset of 4 differentially expressed exosomal miRNAs, even in the absence of parallel changes in systemic blood pressure or metabolic function. CONCLUSIONS Circulating exosomes facilitate important intercellular signals that modify endothelial phenotype, and thus emerge as potential fundamental contributors in the context of OSA/OHS-related endothelial dysfunction. Exosomes may not only provide candidate biomarkers, but are also a likely and plausible mechanism toward OSA/OHS-induced cardiovascular disease. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov, Title: AVAPS-AE Efficacy Study, URL: https://clinicaltrials.gov/ct2/show/NCT01368614, Identifier: NCT01368614.
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Affiliation(s)
- Rakesh Bhattacharjee
- Division of Respiratory Medicine, Department of Pediatrics, Rady Children's Hospital, The University of California San Diego, San Diego, California
| | - Abdelnaby Khalyfa
- Section of Sleep Medicine, Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division University of Chicago, Chicago, Illinois
| | - Ahamed A Khalyfa
- Section of Sleep Medicine, Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division University of Chicago, Chicago, Illinois
| | - Babak Mokhlesi
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Leila Kheirandish-Gozal
- Section of Sleep Medicine, Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division University of Chicago, Chicago, Illinois
| | | | - Eduard Peris
- Section of Sleep Medicine, Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division University of Chicago, Chicago, Illinois
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California San Diego, San Diego, California
| | - David Gozal
- Section of Sleep Medicine, Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division University of Chicago, Chicago, Illinois
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40
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McEvoy RD, Kohler M. Con: continuous positive airway pressure and cardiovascular prevention. Eur Respir J 2018; 51:51/5/1702721. [PMID: 29748242 DOI: 10.1183/13993003.02721-2017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Accepted: 04/19/2018] [Indexed: 01/27/2023]
Affiliation(s)
- R Doug McEvoy
- Sleep Health Service, SALHN, Respiratory and Sleep Services, Adelaide, Australia.,Adelaide Institute for Sleep Health, Flinders University, Adelaide, Australia
| | - Malcolm Kohler
- Dept of Pulmonology, University Hospital of Zurich, Zurich, Switzerland.,Center of Interdisciplinary Sleep Research, University of Zurich, Zurich, Switzerland
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41
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Torres G, Turino C, Sapiña E, Sánchez-de-la-Torre M, Barbé F. Sleep Apnea and Cardiovascular Morbidity—a Perspective. CURRENT SLEEP MEDICINE REPORTS 2018. [DOI: 10.1007/s40675-018-0108-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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42
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Sutherland K, Almeida FR, de Chazal P, Cistulli PA. Prediction in obstructive sleep apnoea: diagnosis, comorbidity risk, and treatment outcomes. Expert Rev Respir Med 2018; 12:293-307. [DOI: 10.1080/17476348.2018.1439743] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Kate Sutherland
- Department of Respiratory & Sleep Medicine, Royal North Shore Hospital, Sydney, Australia
- Charles Perkins Centre, University of Sydney, Sydney, Australia
| | | | - Philip de Chazal
- Charles Perkins Centre, University of Sydney, Sydney, Australia
- School of Electrical and Information Engineering, University of Sydney, Sydney, Australia
| | - Peter A. Cistulli
- Department of Respiratory & Sleep Medicine, Royal North Shore Hospital, Sydney, Australia
- Charles Perkins Centre, University of Sydney, Sydney, Australia
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43
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Torres Cortada G, Sacristán García O. Identificar el síndrome de apneas-hipopneas del sueño en la consulta de riesgo cardiovascular: evaluando el porqué y el cómo. HIPERTENSION Y RIESGO VASCULAR 2018; 35:1-4. [PMID: 29405959 DOI: 10.1016/j.hipert.2018.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 01/09/2018] [Indexed: 10/18/2022]
Affiliation(s)
- Gerard Torres Cortada
- Unidad de Factores de Riesgo Cardiovascular, Hospital Universitario de Santa Maria, Lleida, España; Institut de Recerca Biomèdica (IRB), Lleida, España.
| | - Oscar Sacristán García
- Unidad de Factores de Riesgo Cardiovascular, Hospital Universitario de Santa Maria, Lleida, España; Universidad de Lleida (UDL), Lleida, España
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44
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Tamisier R, Lévy P. Management of hypertension in obstructive sleep apnoea: predicting blood pressure reduction under continuous positive airway pressure. Eur Respir J 2017; 50:50/4/1701822. [PMID: 28982770 DOI: 10.1183/13993003.01822-2017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 09/05/2017] [Indexed: 11/05/2022]
Affiliation(s)
- Renaud Tamisier
- Univ. Grenoble Alpes, Inserm, HP2 Laboratory, Grenoble, France.,Sleep Laboratory, Thorax and Vessels Dept, Grenoble Alpes University Hospital, Grenoble, France
| | - Patrick Lévy
- Univ. Grenoble Alpes, Inserm, HP2 Laboratory, Grenoble, France .,Sleep Laboratory, Thorax and Vessels Dept, Grenoble Alpes University Hospital, Grenoble, France
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