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Mao Z, Zheng P, Zhu X, Wang L, Zhang F, Liu H, Li H, Zhou L, Liu W. Obstructive sleep apnea hypopnea syndrome and vascular lesions: An update on what we currently know. Sleep Med 2024; 119:296-311. [PMID: 38723575 DOI: 10.1016/j.sleep.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 04/23/2024] [Accepted: 05/02/2024] [Indexed: 06/18/2024]
Abstract
Obstructive sleep apnea-hypopnea syndrome (OSAHS) is the most prevalent sleep and respiratory disorder. This syndrome can induce severe cardiovascular and cerebrovascular complications, and intermittent hypoxia is a pivotal contributor to this damage. Vascular pathology is closely associated with the impairment of target organs, marking a focal point in current research. Vascular lesions are the fundamental pathophysiological basis of multiorgan ailments and indicate a shared pathogenic mechanism among common cardiovascular and cerebrovascular conditions, suggesting their importance as a public health concern. Increasing evidence shows a strong correlation between OSAHS and vascular lesions. Previous studies predominantly focused on the pathophysiological alterations in OSAHS itself, such as intermittent hypoxia and fragmented sleep, leading to vascular disruptions. This review aims to delve deeper into the vascular lesions affected by OSAHS by examining the microscopic pathophysiological mechanisms involved. Emphasis has been placed on examining how OSAHS induces vascular lesions through disruptions in the endothelial barrier, metabolic dysregulation, cellular phenotype alterations, neuroendocrine irregularities, programmed cell death, vascular inflammation, oxidative stress and epigenetic modifications. This review examines the epidemiology and associated risk factors for OSAHS and vascular diseases and subsequently describes the existing evidence on vascular lesions induced by OSAHS in the cardiovascular, cerebrovascular, retinal, renal and reproductive systems. A detailed account of the current research on the pathophysiological mechanisms mediating vascular lesions caused by OSAHS is provided, culminating in a discussion of research advancements in therapeutic modalities to mitigate OSAHS-related vascular lesions and the implications of these treatment strategies.
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Affiliation(s)
- Zhenyu Mao
- Department of Respiratory and Critical Care Medicine, National Health Committee (NHC) Key Laboratory of Respiratory Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Pengdou Zheng
- Department of Respiratory and Critical Care Medicine, National Health Committee (NHC) Key Laboratory of Respiratory Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoyan Zhu
- Department of Respiratory and Critical Care Medicine, National Health Committee (NHC) Key Laboratory of Respiratory Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lingling Wang
- Department of Respiratory and Critical Care Medicine, National Health Committee (NHC) Key Laboratory of Respiratory Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fengqin Zhang
- Department of Respiratory and Critical Care Medicine, National Health Committee (NHC) Key Laboratory of Respiratory Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huiguo Liu
- Department of Respiratory and Critical Care Medicine, National Health Committee (NHC) Key Laboratory of Respiratory Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hai Li
- Department of Geriatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China; Key Laboratory of Vascular Aging, Ministry of Education, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China
| | - Ling Zhou
- Department of Respiratory and Critical Care Medicine, National Health Committee (NHC) Key Laboratory of Respiratory Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Wei Liu
- Department of Geriatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China; Key Laboratory of Vascular Aging, Ministry of Education, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China.
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Le Guével X, Josserand V, Harki O, Baulin VA, Henry M, Briançon-Marjollet A. Real-time visualization of dextran extravasation in intermittent hypoxia mice using noninvasive SWIR imaging. Am J Physiol Heart Circ Physiol 2024; 326:H900-H906. [PMID: 38363213 DOI: 10.1152/ajpheart.00787.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/29/2024] [Accepted: 01/29/2024] [Indexed: 02/17/2024]
Abstract
Imaging tools are crucial for studying the vascular network and its barrier function in various physiopathological conditions. Shortwave infrared (SWIR) window optical imaging allows noninvasive, in-depth exploration. We applied SWIR imaging, combined with vessel segmentation and deep learning analyses, to study real-time dextran probe extravasation in mice experiencing intermittent hypoxia (IH)-a characteristic of obstructive sleep apnea associated with potential cardiovascular alterations due to early vascular permeability. Evidence for permeability in this context is limited, making our investigation significant. C57Bl/6 mice were exposed to normoxia or intermittent hypoxia for 14 days. Then SWIR imaging between 1,250 and 1,700 nm was performed on the saphenous artery and vein and on the surrounding tissue after intravenous injection of labeled dextrans of two different sizes (10 or 70 kDa). Postprocessing and segmentation of the SWIR images were conducted using deep learning treatment. We monitored high-resolution signals, distinguishing arteries, veins, and surrounding tissues. In the saphenous artery and vein, after 70-kD dextran injection, tissue/vessel ratio was higher after intermittent hypoxia (IH) than normoxia (N) over 500 seconds (P < 0.05). However, the ratio was similar in N and IH after 10-kD dextran injection. The SWIR imaging technique allows noninvasive, real-time monitoring of dextran extravasation in vivo. Dextran 70 extravasation is increased after exposure to IH, suggesting an increased vessel permeability in this mice model of obstructive sleep apnea.NEW & NOTEWORTHY We demonstrate that SWIR imaging technique is a useful tool to monitor real-time dextran extravasation from vessels in vivo, with a high resolution. We report for the first time an increased real-time dextran (70 kD) extravasation in mice exposed to intermittent hypoxia for 14 days compared with normoxic controls.
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Affiliation(s)
- Xavier Le Guével
- University grenoble alpes, Institute for Advanced Biosciences, NSERM1209/CNRS-UMR5309, Grenoble, France
| | - Véronique Josserand
- University grenoble alpes, Institute for Advanced Biosciences, NSERM1209/CNRS-UMR5309, Grenoble, France
| | - Olfa Harki
- University grenoble alpes, INSERM U1300, HP2 Laboratory, Grenoble, France
| | - Vladimir A Baulin
- Departament Química Física i Inorgànica, Universitat Rovira i Virgili, Tarragona, Spain
| | - Maxime Henry
- University grenoble alpes, Institute for Advanced Biosciences, NSERM1209/CNRS-UMR5309, Grenoble, France
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Lenka J, Foley R, Metersky M, Salmon A. Relationship between obstructive sleep apnea and pulmonary hypertension: past, present and future. Expert Rev Respir Med 2024; 18:85-97. [PMID: 38646681 DOI: 10.1080/17476348.2024.2345684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 04/17/2024] [Indexed: 04/23/2024]
Abstract
INTRODUCTION Obstructive sleep apnea (OSA) is a widely prevalent condition with consequent multiple organ systems complications. There is consensus that OSA is associated with negative effects on pulmonary hemodynamics but whether it contributes to development of clinical pulmonary hypertension (PH) is unclear. AREAS COVERED In this review, we (1) highlight previous studies looking into the possible bidirectional association of OSA and PH, focusing on those that explore clinical prognostic implications, (2) explore potential pathophysiology, (3) discuss the new metrics in OSA, (4) describe endo-phenotyping of OSA, (5) recommend possible risk assessment and screening pathways. EXPERT OPINION Relying only on symptoms to consider a sleep study in PH patients is a missed opportunity to detect OSA, which, if present and not treated, can worsen outcomes. The potential prognostic role of sleep study metrics such as oxygen desaturation index (ODI), hypoxic burden (HB) and ventilatory burden (VB) in OSA should be studied in prospective trials to identify patients at risk for PH. AHI alone has not provided clarity. In those with PH, we should consider replacing ambulatory overnight pulse oximetry (OPO) with home sleep studies (HST). In PH patients, mild OSA should be sufficient to consider PAP therapy.
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Affiliation(s)
- Jyotirmayee Lenka
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Connecticut, Farmington, CT, USA
| | - Raymond Foley
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Connecticut, Farmington, CT, USA
| | - Mark Metersky
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Connecticut, Farmington, CT, USA
| | - Adrian Salmon
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Connecticut, Farmington, CT, USA
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Bonsignore MR. Adaptive responses to chronic intermittent hypoxia: contributions from the European Sleep Apnoea Database (ESADA) Cohort. J Physiol 2023; 601:5467-5480. [PMID: 37218069 DOI: 10.1113/jp284108] [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: 02/01/2023] [Accepted: 05/18/2023] [Indexed: 05/24/2023] Open
Abstract
Obstructive sleep apnoea (OSA) is a common disease in the general population, and is associated with increased cardiovascular risk and several comorbidities. Obesity favours upper airway collapsibility, but other pathophysiological traits have been identified, i.e. upper airway muscle activity, modulation of the respiratory drive, and the arousal threshold. OSA causes chronic intermittent hypoxia, inflammatory activation and autonomic imbalance with diurnal and nocturnal sympathetic hyperactivity. Disentangling so many components to investigate the pathogenesis of OSA's consequences is very hard clinically. However, albeit imperfect, clinical medicine constitutes a major source of inspiration for basic research, and a mutual exchange of information is essential between clinicians and physiologists to improve our understanding of disease states. OSA is no exception, and this narrative review will summarize the results of clinical studies performed over the years by the European Sleep Apnoea Database (ESADA) Study Group, to explore the variables linked to markers of intermittent hypoxia as opposed to the traditional assessment of OSA severity based on the frequency of respiratory events during sleep (the Apnoea Hypopnoea Index). The results of the clinical studies indicate that intermittent hypoxia variables are associated with several comorbidities, although evidence of a cause-effect relationship is still missing in many cases. It is also possible that adaptive rather than maladaptive responses could be evoked by intermittent hypoxia. The intensity, duration and frequency of intermittent hypoxia episodes causing adaptive rather than maladaptive responses, and their clinical implications, deserve further investigation.
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Affiliation(s)
- Maria R Bonsignore
- PROMISE Department, University of Palermo, Palermo, Italy
- Sleep Disordered Breathing Clinic, Division of Pneumology, V. Cervello Hospital, Palermo, Italy
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Iturriaga R. Carotid body contribution to the physio-pathological consequences of intermittent hypoxia: role of nitro-oxidative stress and inflammation. J Physiol 2023; 601:5495-5507. [PMID: 37119020 DOI: 10.1113/jp284112] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/24/2023] [Indexed: 04/30/2023] Open
Abstract
Obstructive sleep apnoea (OSA), characterized by chronic intermittent hypoxia (CIH), is considered to be an independent risk for hypertension. The pathological cardiorespiratory consequences of OSA have been attributed to systemic oxidative stress, inflammation and sympathetic overflow induced by CIH, but an emerging body of evidence indicates that a nitro-oxidative and pro-inflammatory milieu within the carotid body (CB) is involved in the potentiation of CB chemosensory responses to hypoxia, which contribute to enhance the sympathetic activity. Accordingly, autonomic and cardiovascular alterations induced by CIH are critically dependent on an abnormally heightened CB chemosensory input to the nucleus of tractus solitarius (NTS), where second-order neurons project onto the rostral ventrolateral medulla (RVLM), activating pre-sympathetic neurons that control pre-ganglionic sympathetic neurons. CIH produces oxidative stress and neuroinflammation in the NTS and RVLM, which may contribute to the long-term irreversibility of the CIH-induced alterations. This brief review is mainly focused on the contribution of nitro-oxidative stress and pro-inflammatory molecules on the hyperactivation of the hypoxic chemoreflex pathway including the CB and the brainstem centres, and whether the persistence of autonomic and cardiorespiratory alterations may depend on the glial-related neuroinflammation induced by the enhanced CB chemosensory afferent input.
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Affiliation(s)
- Rodrigo Iturriaga
- Laboratorio de Neurobiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
- Centro de Investigación en Fisiología y Medicina de Altura, Facultad de Ciencias de la Salud, Universidad de Antofagasta, Antofagasta, Chile
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Breville G, Herrmann F, Adler D, Deffert C, Bommarito G, Stancu P, Accorroni A, Uginet M, Assal F, Tamisier R, Lalive PH, Pepin JL, Lövblad KO, Allali G. Obstructive sleep apnea: a major risk factor for COVID-19 encephalopathy? BMC Neurol 2023; 23:340. [PMID: 37752429 PMCID: PMC10523731 DOI: 10.1186/s12883-023-03393-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 09/15/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND This study evaluates the impact of high risk of obstructive sleep apnea (OSA) on coronavirus disease 2019 (COVID-19) acute encephalopathy (AE). METHODS Between 3/1/2020 and 11/1/2021, 97 consecutive patients were evaluated at the Geneva University Hospitals with a neurological diagnosis of COVID-19 AE. They were divided in two groups depending on the presence or absence of high risk for OSA based on the modified NOSAS score (mNOSAS, respectively ≥ 8 and < 8). We compared patients' characteristics (clinical, biological, brain MRI, EEG, pulmonary CT). The severity of COVID-19 AE relied on the RASS and CAM scores. RESULTS Most COVID-19 AE patients presented with a high mNOSAS, suggesting high risk of OSA (> 80%). Patients with a high mNOSAS had a more severe form of COVID-19 AE (84.8% versus 27.8%), longer mean duration of COVID-19 AE (27.9 versus 16.9 days), higher mRS at discharge (≥ 3 in 58.2% versus 16.7%), and increased prevalence of brain vessels enhancement (98.1% versus 20.0%). High risk of OSA was associated with a 14 fold increased risk of developing a severe COVID-19 AE (OR = 14.52). DISCUSSION These observations suggest an association between high risk of OSA and COVID-19 AE severity. High risk of OSA could be a predisposing factor leading to severe COVID-19 AE and consecutive long-term sequalae.
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Affiliation(s)
- Gautier Breville
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.
- Department of Neurosciences, Division of Neurology, Geneva University Hospitals, Geneva, Switzerland.
| | - François Herrmann
- Department of Rehabilitation and Geriatrics, Division of Geriatrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Dan Adler
- Division of Pneumology, La Tour Hospital, Geneva, Switzerland
| | - Christine Deffert
- Laboratory of Biological Fluids, Laboratory Medicine Division, Diagnostic Department, Geneva University Hospitals, Geneva, Switzerland
- Laboratory Medicine Division, Department of Medical Specialties, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Giulia Bommarito
- Leenaards Memory Center, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Patrick Stancu
- Department of Neurosciences, Division of Neurology, Geneva University Hospitals, Geneva, Switzerland
| | - Alice Accorroni
- Department of Neurosciences, Division of Neurology, Geneva University Hospitals, Geneva, Switzerland
| | - Marjolaine Uginet
- Department of Neurosciences, Division of Neurology, Geneva University Hospitals, Geneva, Switzerland
| | - Frederic Assal
- Department of Neurosciences, Division of Neurology, Geneva University Hospitals, Geneva, Switzerland
| | - Renaud Tamisier
- Univ. Grenoble Alpes, INSERM, CHU Grenoble Alpes, HP2, 38000, Grenoble, France
| | - Patrice H Lalive
- Department of Neurosciences, Division of Neurology, Geneva University Hospitals, Geneva, Switzerland
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Diagnostic Department, Division of Laboratory Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Jean-Louis Pepin
- Division of Pneumology, La Tour Hospital, Geneva, Switzerland
- Univ. Grenoble Alpes, INSERM, CHU Grenoble Alpes, HP2, 38000, Grenoble, France
| | - Karl-Olof Lövblad
- Division of Neuroradiology, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Gilles Allali
- Department of Neurosciences, Division of Neurology, Geneva University Hospitals, Geneva, Switzerland
- Leenaards Memory Center, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Department of Neurology, Division of Cognitive and Motor Aging, Albert Einstein College of Medicine, Yeshiva University, Bronx, NY, USA
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Bradicich M, Siciliano M, Donfrancesco F, Cherneva R, Ferraz B, Testelmans D, Sánchez-de-la-Torre M, Randerath W, Schiza S, Cruz J. Sleep and Breathing Conference highlights 2023: a summary by ERS Assembly 4. Breathe (Sheff) 2023; 19:230168. [PMID: 38020339 PMCID: PMC10644110 DOI: 10.1183/20734735.0168-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 10/08/2023] [Indexed: 12/01/2023] Open
Abstract
This paper presents some of the highlights of the Sleep and Breathing Conference 2023 https://bit.ly/46MxJml.
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Affiliation(s)
- Matteo Bradicich
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- Department of Internal Medicine, Spital Zollikerberg, Zollikerberg, Switzerland
| | - Matteo Siciliano
- Università Cattolica del Sacro Cuore, Campus di Roma, Rome, Italy
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- These authors contributed equally
| | - Federico Donfrancesco
- Università Cattolica del Sacro Cuore, Campus di Roma, Rome, Italy
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- These authors contributed equally
| | - Radostina Cherneva
- Medical University, University Hospital “Ivan Rilski”, Respiratory Intensive Care Unit, Sofia, Bulgaria
- These authors contributed equally
| | - Beatriz Ferraz
- Pulmonology Department, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- These authors contributed equally
| | - Dries Testelmans
- Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
- These authors contributed equally
| | - Manuel Sánchez-de-la-Torre
- Respiratory Department, Hospital Universitari Arnau de Vilanova-Santa María, IRB Lleida, Lleida, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Winfried Randerath
- Institute of Pneumology, University Cologne, Bethanien Hospital, Solingen, Germany
- These authors contributed equally
| | - Sophia Schiza
- Department of Respiratory Medicine, School of Medicine, University of Crete, Heraklion, Greece
- These authors contributed equally
| | - Joana Cruz
- Center for Innovative Care and Health Technology (ciTechCare), School of Health Sciences (ESSLei), Polytechnic of Leiria, Leiria, Portugal
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González-Candia A, Candia AA, Arias PV, Paz AA, Herrera EA, Castillo RL. Chronic intermittent hypobaric hypoxia induces cardiovascular dysfunction in a high-altitude working shift model. Life Sci 2023:121800. [PMID: 37245841 DOI: 10.1016/j.lfs.2023.121800] [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: 02/03/2023] [Revised: 05/17/2023] [Accepted: 05/20/2023] [Indexed: 05/30/2023]
Abstract
AIMS Chronic intermittent hypobaric hypoxia (CIHH) exposure due to shift work occurs mainly in 4 × 4 or 7 × 7 days shifts in mining, astronomy, and customs activities, among other institutions. However, the long-lasting effects of CIHH on cardiovascular structure and function are not well characterized. We aimed to investigate the effects of CIHH on the cardiac and vascular response of adult rats simulating high-altitude (4600 m) x low-altitude (760 m) working shifts. MAIN METHODS We analyzed in vivo cardiac function through echocardiography, ex vivo vascular reactivity by wire myography, and in vitro cardiac morphology by histology and protein expression and immunolocalization by molecular biology and immunohistochemistry techniques in 12 rats, 6 exposed to CIHH in the hypoxic chamber, and respective normobaric normoxic controls (n = 6). KEY FINDINGS CIHH induced cardiac dysfunction with left and right ventricle remodeling, associated with an increased collagen content in the right ventricle. In addition, CIHH increased HIF-1α levels in both ventricles. These changes are associated with decreased antioxidant capacity in cardiac tissue. Conversely, CIHH decreased contractile capacity with a marked decreased in nitric oxide-dependent vasodilation in both, carotid and femoral arteries. SIGNIFICANCE These data suggest that CIHH induces cardiac and vascular dysfunction by ventricular remodeling and impaired vascular vasodilator function. Our findings highlight the impact of CIHH in cardiovascular function and the importance of a periodic cardiovascular evaluation in high-altitude workers.
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Affiliation(s)
| | - Alejandro A Candia
- Institute of Health Sciences, University of O'Higgins, Rancagua, Chile; Department for the Woman and Newborn Health Promotion, Universidad de Chile, Chile
| | - Pamela V Arias
- Laboratory of Vascular Function & Reactivity, Pathophysiology Program, ICBM, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Adolfo A Paz
- Laboratory of Vascular Function & Reactivity, Pathophysiology Program, ICBM, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Emilio A Herrera
- Laboratory of Vascular Function & Reactivity, Pathophysiology Program, ICBM, Faculty of Medicine, Universidad de Chile, Santiago, Chile; International Center for Andean Studies (INCAS), University of Chile, Putre, Chile.
| | - Rodrigo L Castillo
- Departamento de Medicina Interna Oriente, Facultad de Medicina, Universidad de Chile, Santiago, Chile; Unidad de Paciente Crítico, Hospital del Salvador, Santiago, Chile.
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Syndrome d’apnées du sommeil 1999–2022 : des essais randomisés aux études de cohorte. BULLETIN DE L'ACADÉMIE NATIONALE DE MÉDECINE 2023. [DOI: 10.1016/j.banm.2022.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
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10
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Badran M, Khalyfa A, Ericsson AC, Puech C, McAdams Z, Bender SB, Gozal D. Gut microbiota mediate vascular dysfunction in a murine model of sleep apnoea: effect of probiotics. Eur Respir J 2023; 61:2200002. [PMID: 36028255 DOI: 10.1183/13993003.00002-2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 08/10/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Obstructive sleep apnoea (OSA) is a chronic prevalent condition characterised by intermittent hypoxia (IH), and is associated with endothelial dysfunction and coronary artery disease (CAD). OSA can induce major changes in gut microbiome diversity and composition, which in turn may induce the emergence of OSA-associated morbidities. However, the causal effects of IH-induced gut microbiome changes on the vasculature remain unexplored. Our objective was to assess if vascular dysfunction induced by IH is mediated through gut microbiome changes. METHODS Faecal microbiota transplantation (FMT) was conducted on C57BL/6J naïve mice for 6 weeks to receive either IH or room air (RA) faecal slurry with or without probiotics (VSL#3). In addition to 16S rRNA amplicon sequencing of their gut microbiome, FMT recipients underwent arterial blood pressure and coronary artery and aorta function testing, and their trimethylamine N-oxide (TMAO) and plasma acetate levels were determined. Finally, C57BL/6J mice were exposed to IH, IH treated with VSL#3 or RA for 6 weeks, and arterial blood pressure and coronary artery function assessed. RESULTS Gut microbiome taxonomic profiles correctly segregated IH from RA in FMT mice and the normalising effect of probiotics emerged. Furthermore, IH-FMT mice exhibited increased arterial blood pressure and TMAO levels, and impairments in aortic and coronary artery function (p<0.05) that were abrogated by probiotic administration. Lastly, treatment with VSL#3 under IH conditions did not attenuate elevations in arterial blood pressure or CAD. CONCLUSIONS Gut microbiome alterations induced by chronic IH underlie, at least partially, the typical cardiovascular disturbances of sleep apnoea and can be mitigated by concurrent administration of probiotics.
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Affiliation(s)
- Mohammad Badran
- Department of Child Health and Child Health Research Institute, School of Medicine, University of Missouri, Columbia, MO, USA
| | - Abdelnaby Khalyfa
- Department of Child Health and Child Health Research Institute, School of Medicine, University of Missouri, Columbia, MO, USA
| | - Aaron C Ericsson
- Department of Veterinary Pathobiology, University of Missouri, Columbia, MO, USA
- University of Missouri Metagenomics Center, University of Missouri, Columbia, MO, USA
| | - Clementine Puech
- Department of Child Health and Child Health Research Institute, School of Medicine, University of Missouri, Columbia, MO, USA
| | - Zachary McAdams
- Department of Molecular Microbiology and Immunology, Molecular Pathogenesis and Therapeutics Program, University of Missouri, Columbia, MO, USA
| | - Shawn B Bender
- Dalton Cardiovascular Research Center, University of Missouri, Columbia, MO, USA
- Department of Biomedical Sciences, University of Missouri, Columbia, MO, USA
- Harry S. Truman Memorial Veterans Hospital, University of Missouri, Columbia, MO, USA
| | - David Gozal
- Department of Child Health and Child Health Research Institute, School of Medicine, University of Missouri, Columbia, MO, USA
- Department of Medical Pharmacology and Physiology, School of Medicine, University of Missouri, Columbia, MO, USA
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Badran M, Bender SB, Khalyfa A, Padilla J, Martinez-Lemus LA, Gozal D. Temporal changes in coronary artery function and flow velocity reserve in mice exposed to chronic intermittent hypoxia. Sleep 2022; 45:6602135. [DOI: 10.1093/sleep/zsac131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 05/13/2022] [Indexed: 12/15/2022] Open
Abstract
Abstract
Study Objectives
Obstructive sleep apnea (OSA) is a chronic condition characterized by intermittent hypoxia (IH) that is implicated in an increased risk of cardiovascular disease (i.e., coronary heart disease, CHD) and associated with increased overall and cardiac-specific mortality. Accordingly, we tested the hypothesis that experimental IH progressively impairs coronary vascular function and in vivo coronary flow reserve.
Methods
Male C57BL/6J mice (8-week-old) were exposed to IH (FiO2 21% 90 s–6% 90 s) or room air (RA; 21%) 12 h/day during the light cycle for 2, 6, 16, and 28 weeks. Coronary artery flow velocity reserve (CFVR) was measured at each time point using a Doppler system. After euthanasia, coronary arteries were micro-dissected and mounted on wire myograph to assess reactivity to acetylcholine (ACh) and sodium nitroprusside (SNP).
Results
Endothelium-dependent coronary relaxation to ACh was preserved after 2 weeks of IH (80.6 ± 7.8%) compared to RA (87.8 ± 7.8%, p = 0.23), but was significantly impaired after 6 weeks of IH (58.7 ± 16.2%, p = 0.02). Compared to ACh responses at 6 weeks, endothelial dysfunction was more pronounced in mice exposed to 16 weeks (48.2 ± 5.3%) but did not worsen following 28 weeks of IH (44.8 ± 11.6%). A 2-week normoxic recovery after a 6-week IH exposure reversed the ACh abnormalities. CFVR was significantly reduced after 6 (p = 0.0006) and 28 weeks (p < 0.0001) of IH when compared to controls.
Conclusion
Chronic IH emulating the hypoxia-re-oxygenation cycles of moderate-to-severe OSA promotes coronary artery endothelial dysfunction and CFVR reductions in mice, which progressively worsen until reaching asymptote between 16 and 28 weeks. Normoxic recovery after 6 weeks exposure reverses the vascular abnormalities.
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Affiliation(s)
- Mohammad Badran
- Department of Child Health and Child Health Research Institute, School of Medicine, University of Missouri , Columbia, MO , USA
| | - Shawn B Bender
- Dalton Cardiovascular Research Center, University of Missouri , Columbia, MO , USA
- Department of Biomedical Sciences, University of Missouri , Columbia, MO , USA
- Research Service, Harry S. Truman Memorial Veterans Hospital , Columbia, MO , USA
| | - Abdelnaby Khalyfa
- Department of Child Health and Child Health Research Institute, School of Medicine, University of Missouri , Columbia, MO , USA
| | - Jaume Padilla
- Dalton Cardiovascular Research Center, University of Missouri , Columbia, MO , USA
- Department of Nutrition and Exercise Physiology, University of Missouri , Columbia, MO , USA
| | - Luis A Martinez-Lemus
- Dalton Cardiovascular Research Center, University of Missouri , Columbia, MO , USA
- Department of Medical Pharmacology and Physiology, School of Medicine, University of Missouri , Columbia, MO , USA
| | - David Gozal
- Department of Child Health and Child Health Research Institute, School of Medicine, University of Missouri , Columbia, MO , USA
- Department of Medical Pharmacology and Physiology, School of Medicine, University of Missouri , Columbia, MO , USA
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12
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Belaidi E, Khouri C, Harki O, Baillieul S, Faury G, Briançon-Marjollet A, Pépin JL, Arnaud C. Cardiac consequences of intermittent hypoxia: a matter of dose? A systematic review and meta-analysis in rodents. Eur Respir Rev 2022; 31:31/164/210269. [PMID: 35418489 PMCID: PMC9171537 DOI: 10.1183/16000617.0269-2021] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 01/24/2022] [Indexed: 12/21/2022] Open
Abstract
Aim Intermittent hypoxia (IH) is considered to be a major contributor to obstructive sleep apnoea-related cardiovascular consequences. The present meta-analysis aimed to assess the effects of IH on cardiac remodelling, function and infarct size after myocardial ischaemia across different rodent species and IH severities. Methods and results Relevant articles from PubMed, Embase and Web of Science were screened. We performed a random effect meta-analysis to assess the effect of IH on myocardium in rodents by using standardised mean difference (SMD). Studies using rodents exposed to IH and outcomes related to cardiac remodelling, contractile function and response to myocardial ischaemia–reperfusion were included. 5217 articles were screened and 92 were included, demonstrating that IH exposure induced cardiac remodelling, characterised by cardiomyocyte hypertrophy (cross-sectional area: SMD=2.90, CI (0.82–4.98), I2=94.2%), left ventricular (LV) dilation (LV diameter: SMD=0.64, CI (0.18–1.10), I2=88.04%), interstitial fibrosis (SMD=5.37, CI (3.22–7.53), I2=94.8) and apoptosis (terminal deoxynucleotidyl transferase dUTP nick end labelling: SMD=6.70, CI (2.96–10.44), I2=95.9). These structural changes were accompanied by a decrease in LV ejection fraction (SMD=−1.82, CI (−2.52–−1.12), I2=94.22%). Importantly, most of the utilised IH protocols mimicked extremely severe hypoxic disease. Concerning infarct size, meta-regression analyses highlighted an ambivalent role of IH, depending on its severity. Indeed, IH exposure with inspiratory oxygen fraction (FIO2) <7% was associated with an increase in infarct size, whereas a reduced infarct size was reported for FIO2 levels above 10%. Heterogeneity between studies, small study effect and poor reporting of methods in included articles limited the robustness of the meta-analysis findings. Conclusion This meta-analysis demonstrated that severe IH systematically induces cardiac remodelling and contractile dysfunction in rodents, which might trigger or aggravate chronic heart failure. Interestingly, this meta-analysis showed that, depending on stimulus severity, IH exhibits both protective and aggravating effects on infarct size after experimental ischaemia–reperfusion procedures. This meta-analysis shows that IH induces cardiac remodelling and contractile dysfunction in rodents, independently of IH characteristics. Conversely, the dual response to myocardial ischaemia–reperfusion seems to be related to IH intensity and duration.https://bit.ly/3rdnR32
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Affiliation(s)
- Elise Belaidi
- Univ. Grenoble Alpes, INSERM, CHU Grenoble Alpes, HP2, Grenoble, France .,These authors contributed equally to this work
| | - Charles Khouri
- Univ. Grenoble Alpes, INSERM, CHU Grenoble Alpes, HP2, Grenoble, France.,Pharmacovigilance Unit and Clinical Pharmacology Dept, Grenoble Alpes University Hospital, Grenoble, France.,These authors contributed equally to this work
| | - Olfa Harki
- Univ. Grenoble Alpes, INSERM, CHU Grenoble Alpes, HP2, Grenoble, France
| | | | - Gilles Faury
- Univ. Grenoble Alpes, INSERM, CHU Grenoble Alpes, HP2, Grenoble, France
| | | | - Jean-Louis Pépin
- Univ. Grenoble Alpes, INSERM, CHU Grenoble Alpes, HP2, Grenoble, France
| | - Claire Arnaud
- Univ. Grenoble Alpes, INSERM, CHU Grenoble Alpes, HP2, Grenoble, France
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13
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Harki O, Bouyon S, Sallé M, Arco-Hierves A, Lemarié E, Demory A, Chirica C, Vilgrain I, Pépin JL, Faury G, Briançon-Marjollet A. Inhibition of Vascular Endothelial Cadherin Cleavage Prevents Elastic Fiber Alterations and Atherosclerosis Induced by Intermittent Hypoxia in the Mouse Aorta. Int J Mol Sci 2022; 23:ijms23137012. [PMID: 35806017 PMCID: PMC9266969 DOI: 10.3390/ijms23137012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/17/2022] [Accepted: 06/21/2022] [Indexed: 01/27/2023] Open
Abstract
Intermittent hypoxia (IH), the major feature of obstructive sleep apnea syndrome (OSAS), induces atherosclerosis and elastic fiber alterations. VE-cadherin cleavage is increased in OSAS patients and in an IH-cellular model. It is mediated by HIF-1 and Src-tyr-kinases pathways and results in endothelial hyperpermeability. Our aim was to determine whether blocking VE-cadherin cleavage in vivo could be an efficient strategy to inhibit deleterious IH-induced vascular remodeling, elastic fiber defects and atherogenesis. VE-cadherin regulation, aortic remodeling and atherosclerosis were studied in IH-exposed C57Bl/6J or ApoE-/-mice treated or not with Src-tyr-kinases inhibitors (Saracatinib/Pazopanib) or a HIF-1 inhibitor (Acriflavine). Human aortic endothelial cells were exposed to IH and treated with the same inhibitors. LDL and the monocytes transendothelium passage were measured. In vitro, IH increased transendothelium LDL and monocytes passage, and the tested inhibitors prevented these effects. In mice, IH decreased VE-cadherin expression and increased plasmatic sVE level, intima-media thickness, elastic fiber alterations and atherosclerosis, while the inhibitors prevented these in vivo effects. In vivo inhibition of HIF-1 and Src tyr kinase pathways were associated with the prevention of IH-induced elastic fiber/lamella degradation and atherogenesis, which suggests that VE-cadherin could be an important target to limit atherogenesis and progression of arterial stiffness in OSAS.
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Affiliation(s)
- Olfa Harki
- Université Grenoble Alpes, INSERM U1300, CHU Grenoble Alpes, Laboratoire HP2, 38042 Grenoble, France; (O.H.); (S.B.); (M.S.); (A.A.-H.); (E.L.); (A.D.); (J.-L.P.); (A.B.-M.)
| | - Sophie Bouyon
- Université Grenoble Alpes, INSERM U1300, CHU Grenoble Alpes, Laboratoire HP2, 38042 Grenoble, France; (O.H.); (S.B.); (M.S.); (A.A.-H.); (E.L.); (A.D.); (J.-L.P.); (A.B.-M.)
| | - Marine Sallé
- Université Grenoble Alpes, INSERM U1300, CHU Grenoble Alpes, Laboratoire HP2, 38042 Grenoble, France; (O.H.); (S.B.); (M.S.); (A.A.-H.); (E.L.); (A.D.); (J.-L.P.); (A.B.-M.)
| | - Alejandro Arco-Hierves
- Université Grenoble Alpes, INSERM U1300, CHU Grenoble Alpes, Laboratoire HP2, 38042 Grenoble, France; (O.H.); (S.B.); (M.S.); (A.A.-H.); (E.L.); (A.D.); (J.-L.P.); (A.B.-M.)
| | - Emeline Lemarié
- Université Grenoble Alpes, INSERM U1300, CHU Grenoble Alpes, Laboratoire HP2, 38042 Grenoble, France; (O.H.); (S.B.); (M.S.); (A.A.-H.); (E.L.); (A.D.); (J.-L.P.); (A.B.-M.)
| | - Alexandra Demory
- Université Grenoble Alpes, INSERM U1300, CHU Grenoble Alpes, Laboratoire HP2, 38042 Grenoble, France; (O.H.); (S.B.); (M.S.); (A.A.-H.); (E.L.); (A.D.); (J.-L.P.); (A.B.-M.)
| | - Carole Chirica
- Unité Biochimie Immunoanalyse, Service de Biochimie SB2TE, CHU Grenoble Alpes, 38000 Grenoble, France;
| | - Isabelle Vilgrain
- Université Grenoble Alpes, INSERM U1292, CEA, 38042 Grenoble, France;
| | - Jean-Louis Pépin
- Université Grenoble Alpes, INSERM U1300, CHU Grenoble Alpes, Laboratoire HP2, 38042 Grenoble, France; (O.H.); (S.B.); (M.S.); (A.A.-H.); (E.L.); (A.D.); (J.-L.P.); (A.B.-M.)
| | - Gilles Faury
- Université Grenoble Alpes, INSERM U1300, CHU Grenoble Alpes, Laboratoire HP2, 38042 Grenoble, France; (O.H.); (S.B.); (M.S.); (A.A.-H.); (E.L.); (A.D.); (J.-L.P.); (A.B.-M.)
- Correspondence:
| | - Anne Briançon-Marjollet
- Université Grenoble Alpes, INSERM U1300, CHU Grenoble Alpes, Laboratoire HP2, 38042 Grenoble, France; (O.H.); (S.B.); (M.S.); (A.A.-H.); (E.L.); (A.D.); (J.-L.P.); (A.B.-M.)
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Badran M, Gozal D. PAI-1: A Major Player in the Vascular Dysfunction in Obstructive Sleep Apnea? Int J Mol Sci 2022; 23:5516. [PMID: 35628326 PMCID: PMC9141273 DOI: 10.3390/ijms23105516] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/05/2022] [Accepted: 05/12/2022] [Indexed: 02/04/2023] Open
Abstract
Obstructive sleep apnea is a chronic and prevalent condition that is associated with endothelial dysfunction, atherosclerosis, and imposes excess overall cardiovascular risk and mortality. Despite its high prevalence and the susceptibility of CVD patients to OSA-mediated stressors, OSA is still under-recognized and untreated in cardiovascular practice. Moreover, conventional OSA treatments have yielded either controversial or disappointing results in terms of protection against CVD, prompting the need for the identification of additional mechanisms and associated adjuvant therapies. Plasminogen activator inhibitor-1 (PAI-1), the primary inhibitor of tissue-type plasminogen activator (tPA) and urinary-type plasminogen activator (uPA), is a key regulator of fibrinolysis and cell migration. Indeed, elevated PAI-1 expression is associated with major cardiovascular adverse events that have been attributed to its antifibrinolytic activity. However, extensive evidence indicates that PAI-1 can induce endothelial dysfunction and atherosclerosis through complex interactions within the vasculature in an antifibrinolytic-independent matter. Elevated PAI-1 levels have been reported in OSA patients. However, the impact of PAI-1 on OSA-induced CVD has not been addressed to date. Here, we provide a comprehensive review on the mechanisms by which OSA and its most detrimental perturbation, intermittent hypoxia (IH), can enhance the transcription of PAI-1. We also propose causal pathways by which PAI-1 can promote atherosclerosis in OSA, thereby identifying PAI-1 as a potential therapeutic target in OSA-induced CVD.
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Affiliation(s)
- Mohammad Badran
- Department of Child Health and Child Health Research Institute, School of Medicine, University of Missouri, 400 N Keene St, Suite 010, Columbia, MO 65201, USA;
| | - David Gozal
- Department of Child Health and Child Health Research Institute, School of Medicine, University of Missouri, 400 N Keene St, Suite 010, Columbia, MO 65201, USA;
- Department of Medical Pharmacology and Physiology, School of Medicine, University of Missouri, Columbia, MO 65201, USA
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15
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Farré R, Martínez-García MA, Gozal D. Systematic reviews and meta-analyses in animal model research: as necessary, and with similar pros and cons, as in patient research. Eur Respir J 2022; 59:59/3/2102438. [PMID: 35301241 DOI: 10.1183/13993003.02438-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 09/18/2021] [Indexed: 12/22/2022]
Affiliation(s)
- Ramon Farré
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain .,CIBER de Enfermedades Respiratorias, Madrid, Spain.,Institut Investigacions Biomediques August Pi Sunyer, Barcelona, Spain
| | - Miguel A Martínez-García
- CIBER de Enfermedades Respiratorias, Madrid, Spain.,Pneumology Dept, University and Polytechnic la Fe Hospital, Valencia, Spain
| | - David Gozal
- Dept of Child Health, The University of Missouri School of Medicine, Columbia, MO, USA
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16
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Castillo-Galán S, Riquelme B, Iturriaga R. Crucial Role of Stromal Interaction Molecule-Activated TRPC-ORAI Channels in Vascular Remodeling and Pulmonary Hypertension Induced by Intermittent Hypoxia. Front Physiol 2022; 13:841828. [PMID: 35370769 PMCID: PMC8969100 DOI: 10.3389/fphys.2022.841828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 02/09/2022] [Indexed: 11/13/2022] Open
Abstract
Obstructive sleep apnea (OSA), a sleep breathing disorder featured by chronic intermittent hypoxia (CIH), is associate with pulmonary hypertension. Rats exposed to CIH develop lung vascular remodeling and pulmonary hypertension, which paralleled the upregulation of stromal interaction molecule (STIM)-activated TRPC-ORAI Ca2+ channels (STOC) in the lung, suggesting that STOC participate in the pulmonary vascular alterations. Accordingly, to evaluate the role played by STOC in pulmonary hypertension we studied whether the STOC blocker 2-aminoethoxydiphenyl borate (2-APB) may prevent the vascular remodeling and the pulmonary hypertension induced by CIH in a rat model of OSA. We assessed the effects of 2-APB on right ventricular systolic pressure (RVSP), pulmonary vascular remodeling, α-actin and proliferation marker Ki-67 levels in pulmonary arterial smooth muscle cells (PASMC), mRNA levels of STOC subunits, and systemic and pulmonary oxidative stress (TBARS) in male Sprague-Dawley (200 g) rats exposed to CIH (5% O2, 12 times/h for 8h) for 28 days. At 14 days of CIH, osmotic pumps containing 2-APB (10 mg/kg/day) or its vehicle were implanted and rats were kept for 2 more weeks in CIH. Exposure to CIH for 28 days raised RVSP > 35 mm Hg, increased the medial layer thickness and the levels of α-actin and Ki-67 in PASMC, and increased the gene expression of TRPC1, TRPC4, TRPC6 and ORAI1 subunits. Treatment with 2-APB prevented the raise in RVSP and the increment of the medial layer thickness, as well as the increased levels of α-actin and Ki-67 in PASMC, and the increased gene expression of STOC subunits. In addition, 2-APB did not reduced the lung and systemic oxidative stress, suggesting that the effects of 2-APB on vascular remodeling and pulmonary hypertension are independent on the reduction of the oxidative stress. Thus, our results supported that STIM-activated TRPC-ORAI Ca2+ channels contributes to the lung vascular remodeling and pulmonary hypertension induced by CIH.
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Affiliation(s)
- Sebastián Castillo-Galán
- Laboratorio de Neurobiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Bárbara Riquelme
- Laboratorio de Neurobiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Rodrigo Iturriaga
- Laboratorio de Neurobiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
- Centro de Excelencia en Biomedicina de Magallanes (CEBIMA), Universidad de Magallanes, Punta Arenas, Chile
- *Correspondence: Rodrigo Iturriaga,
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