Obstructive sleep apnea increases the risk of cardiovascular damage: a systematic review and meta-analysis of imaging studies

[Relationship between obstructive sleep apnea and type 2 diabetes mellitus]

INTRODUCTION

The association between obstructive sleep apnea (OSA) and glucose metabolism remains controversial. This study investigates the relationship between OSA and incident type 2 diabetes (DM) and prediabetes (preDM), as well as the effect of long-term CPAP (continuous positive airway pressure) treatment.

METHODS

Follow-up study in a retrospective clinical cohort of patients with OSA and randomly selected controls. Data on incident DM and preDM as well as CPAP were obtained from hospital records. The relationship between baseline OSA and incident DM was examined using COX regression models.

RESULTS

Three hundred and fifty-six patients, 169 with OSA and 187 controls were followed for a median of 98 months; 47 patients (13.2%) developed DM and 43 (12.1%) developed preDM. The 5-year cumulative incidence of DM was 10.7% (6.5-13.9%). 87% of subjects with preDM in the baseline sample progressed to incident DM. It is shown that body mass index (BMI), nocturnal hypoxia and apnea hypopnea index (AHI) are risk factors for the development of DM and that CPAP reduces this risk.

CONCLUSIONS

Patients with OSA have a higher risk of developing DM. The risk factors involved are BMI, nocturnal hypoxia and AHI. Regular long-term CPAP use was associated with a decreased risk.

[Diabetes and obstructive sleep apnoea: A case-control study]

INTRODUCTION

Obstructive sleep apnoea (OSA) and diabetes mellitus (DM) are very prevalent diseases frequently associated. Their coexistence is independently associated with an increased prevalence of cardiovascular comorbidities. As this association is underdiagnosed, it is necessary to optimise clinical suspicion by studying independent predictors of DM or prediabetes (preDM) in patients with OSA.

METHOD

A simple randomised case-control study, matched for sex, body mass index (BMI) and age, aimed to study the association of OSA with DM and preDM and to identify independent predictors for both diseases in people with OSA.

RESULTS

We included 208 cases with OSA and 208 controls without OSA. In the former, 18.8% had DM compared to only 10.1% in the latter (P=.00). Prevalence of preDM was 41.8% vs. 10.6%, respectively (P=.00). One hundred and twenty-four cases (59.6%) reported excessive daytime sleepiness (EDS) (Epworth scale, 10.5±3.1) vs. 24.5% of the control group (Epworth scale, 6.6±2.9). Apnoea-hypopnoea index (AHI) and O2 desaturation indices (IDO, CT90 and CT80) were significantly higher in the case group. The risk of MD was related to age, nocturnal hypoxaemia and EDS. The risk of pre-MD was related to BMI and AHI.

CONCLUSIONS

OSA is associated with DM and preDM. Age, nocturnal hypoxaemia and EDS are predictors of DM. BMI and AHI are predictors of pre-MD.

The Influence of Comorbidities on Chemokine and Cytokine Profile in Obstructive Sleep Apnea Patients: Preliminary Results

INTRODUCTION

Obstructive sleep apnea (OSA) is frequently associated with a chronic inflammatory state and cardiovascular/metabolic complications. The aim of this study was to evaluate the influence of certain comorbidities on a panel of 45 chemokines and cytokines in OSA patients with special regard to their possible association with cardiovascular diseases.

MATERIAL AND METHODS

This cross-sectional study was performed on 61 newly diagnosed OSA patients. For the measurement of the plasma concentration of chemokines and cytokines, the magnetic bead-based multiplex assay for the Luminex^® platform was used.

RESULTS

In the patients with concomitant COPD, there were increased levels of pro-inflammatory cytokines (CCL11, CD-40 ligand) and decreased anti-inflammatory cytokine (IL-10), while in diabetes, there were increased levels of pro-inflammatory cytokines (IL-6, TRIAL). Obesity was associated with increased levels of both pro-inflammatory (IL-13) and anti-inflammatory (IL-1RA) cytokines. Hypertension was associated with increased levels of both pro-inflammatory (CCL3) and anti-inflammatory (IL-10) cytokines. Increased daytime pCO₂, low mean nocturnal SaO₂, and the oxygen desaturation index were associated with increased levels of pro-inflammatory cytokines (CXCL1, PDGF-AB, TNF-α, and IL-15).

CONCLUSIONS

In OSA patients with concomitant diabetes and COPD, elevated levels of certain pro-inflammatory and decreased levels of certain anti-inflammatory cytokines may favor the persistence of a chronic inflammatory state with further consequences. Nocturnal hypoxemia, frequent episodes of desaturation, and increased daytime pCO₂ are factors contributing to the chronic inflammatory state in OSA patients.

Disturbed Sleep is Not Good for the Heart: A Narrative Review

Sleep-related breathing disorders, including obstructive sleep apnea (OSA) and central sleep apnea (CSA), have a major impact on cardiovascular function. It has shown an association with hypertension, coronary artery disease, cardiac arrhythmias, sudden cardiac death, and congestive heart failure (CHF). This review focuses on highlighting the relationship between sleep apnea and CHF. We discuss the underlying pathophysiology, which involves the mechanical, neurohormonal, and inflammatory mechanisms; in addition, the similarities and differentiating clinical features of OSA in patients with CHF and without CHF. We have also discussed several treatment strategies, including weight loss, continuous positive airway pressure (CPAP), supplemental oxygen therapy, theophylline, acetazolamide, mandibular advancement device, and hypoglossal nerve stimulation (HGNS). We conclude that since there are several overlapping clinical features in patients with OSA with Heart Failure (HF) and without HF, early detection and treatment are crucial to decrease the risk of HF, coronary artery disease, and stroke.

Obstructive sleep apnea, myocardial perfusion and myocardial blood flow: A study of older male twins

BACKGROUND

Obstructive sleep apnea (OSA) has been associated with incidence of cardiovascular disease and with nocturnal angina, but evidence of a link with coronary atherosclerosis and myocardial ischemia is limited and previous studies may have been affected by selection bias or unmeasured confounding factors.

METHODS

We performed overnight polysomnography in 178 older male twins. The Apnea/Hypopnea Index (AHI) was calculated to assess OSA from the overnight sleep evaluation. AHI ≥15 was used as indicator of moderate/severe OSA. The following day, twins underwent myocardial perfusion imaging with [82Rb]-chloride positron emission tomography. Quantitative and semiquantitative measures of myocardial perfusion and absolute myocardial blood flow were obtained.

RESULTS

The mean age was 68 years and 40% of the sample had an AHI≥15, which indicates moderate to severe OSA. Abnormal myocardial perfusion, both with stress and at rest, was more common in twins with elevated AHI. After adjusting for clinical, lifestyle and behavioral factors, and previous history of cardiovascular disease, twins with AHI ≥15 had 3.6 higher odds (95% CI, 1.5-8.9) of an abnormal total severity score, defined as a score ≥100, and for each 5-point increment in AHI, the odds of abnormality increased by 20% (95% CI, 7%-34%). Twin pairs where both twins had OSA exhibited the greatest risk. There were no differences in measures of ischemia and absolute myocardial blood flow and flow reserve by AHI status.

CONCLUSIONS

OSA is associated with myocardial perfusion abnormalities that suggest prior subclinical myocardial scarring or infarction. Early environmental factors that affect both twins equally may play a role and should be further explored.

Sleep Apnea and Cardiovascular Risk in Patients with Prediabetes and Type 2 Diabetes

Obstructive sleep apnea (OSA) is a common but largely undiagnosed clinical condition, which is turning into a serious public health issue. Of note is that its prevalence is gradually increasing in parallel with the obesity and type 2 diabetes mellitus (T2DM) epidemics. The aim of this article is to comprehensively review the literature in order to evaluate the cardiovascular (CV) risk among patients with OSA and prediabetes or T2DM. OSA seems to be an independent risk factor for the development as well as the progression of T2DM, whereas it is associated with T2DM-related macrovascular and microvascular complications. OSA may also act as a potential risk factor for the presentation and development of CV disease, such as hypertension, coronary artery disease, heart failure, pulmonary hypertension, atrial fibrillation and other cardiac arrythmias, as well as stroke. OSA and T2DM also share common pathophysiological mechanisms leading to atherosclerosis. Considering that the coexistence of OSA and T2DM is an independent and cumulative risk factor for CV mortality, more so than the two diseases separately, clinicians and healthcare professionals should be aware of and screen for OSA in patients with T2DM. Notably, targeted therapy for both conditions seems to substantially improve CV prognosis.

Impact of Obstructive Sleep Apnea Syndrome on Ventricular Remodeling after Acute Myocardial Infarction: A Proof-of-Concept Study

Background: Obstructive sleep apnea syndrome (OSA) is common in patients with acute myocardial infarction (AMI). Whether OSA impacts on the ventricular remodeling post-AMI remains unclear. We compared cardiac ventricular remodeling in patients assessed by cardiac magnetic resonance (CMR) imaging at baseline and six months after AMI based on the presence and severity of OSA. Methods: This prospective study included 47 patients with moderate to severe AMI. They all underwent CMR at inclusion and at six months after an AMI, and a polysomnography was performed three weeks after AMI. Left and right ventricular remodeling parameters were compared between patients based on the AHI, AHI in REM and NREM sleep, oxygen desaturation index, and daytime sleepiness. Results: Of the 47 patients, 49% had moderate or severe OSA with an AHI ≥ 15/h. No differences were observed between these patients and those with an AHI < 15/h for left ventricular end-diastolic and end-systolic volumes at six months. No association was found for left and right ventricular remodeling parameters at six months or for the difference between baseline and six months with polysomnographic parameters of OSA severity, nor with daytime sleepiness. Conclusions: Although with a limited sample size, our proof-of-concept study does not report an association between OSA and ventricular remodeling in patients with AMI. These results highlight the complexity of the relationships between OSA and post-AMI morbi-mortality.

Sleep Apnea Syndrome and Large Artery Subclinical Damage: Targeting Thoracic Aortic Dilatation

AIM

Whether obstructive sleep apnea (OSA) actually represents an independent risk factor for aortic dilation in the general population is unclear. We investigated this issue through a review and a meta-analysis of cardiac imaging studies that provided data on this vascular phenotype measured at the root or ascending tract level.

DESIGN

A computerized search was performed using Pub-Med, OVID, EMBASE, and Cochrane library databases from inception up to 30 November 2021. Studies were identified by using the following search terms: "aortic root," "ascending aorta," "vascular damage," "echocardiography," "computed tomography," "magnetic resonance imaging," "obstructive sleep apnea," "sleep disordered breathing."

RESULTS

Eleven studies including a total of 1,860 patients with OSA (without aortic aneurysms and connective tissue diseases) and 233 non-OSA controls were considered. Aortic diameter was significantly higher in patients with OSA than in non-OSA controls (standard means difference [SMD] = 0.73 ± 0.08, confidence interval [CI]: 0.57-0.88, P < 0.0001). This was also the case for patients with severe OSA as compared with their counterparts with mild OSA (SMD = 0.42 ± 0.07, CI: 0.28-0.56, P < 0.0001).

CONCLUSIONS

Our findings suggest an association between OSA and aortic enlargement and particularly in the severe OSA setting. However, this conclusion must be taken with caution in relation to 2 types of factors: (i) the paucity of available data, and (ii) the limits deriving from the methodological differences of the various studies. Larger prospective and carefully designed studies are needed to shed light on this relevant public health topic.

Symptoms of Nocturnal Masticatory Muscle Activity among Women of Different Age Groups and Their Association to Obstructive Sleep Apnea-A Cross Sectional Study

Sleep bruxism (SB), snoring, and excessive daytime sleepiness are often associated with obstructive sleep apnea (OSA). OSA, which is characterized by a repetitive collapse of the upper airway during sleep, can cause oxygen desaturation and lead to adverse medical conditions, such as cardiovascular events, hypertension, heart attack, and stroke. In the present study, 112 Arab women aged 20−40 years (Early Adulthood/Adulthood−EarlyA) and 116 Arab women aged 50 and above (Middle Age−MiddleA), were requested to complete questionnaires regarding demographic variables, symptoms of nocturnal masticatory muscle activity (possible SB, headache, and stiffness of the oral and/or neck musculature upon awakening), risk of OSA (STOP-BANG questionnaire), and daytime sleepiness (Epworth sleepiness scale—ESS). Women, who reported snoring, experienced more SB (35.8% vs. 20.6%, chi-square, p < 0.05), more headaches (33.3% vs. 19.3%, p < 0.05), and more muscle stiffness upon awakening (34.3% vs. 16.3%, p < 0.005), than their non-snoring counterparts. Out of the women who snore, 11% showed high risk for OSA, as compared to only 1% among the non-snoring participants (p < 0.000). Symptoms of nocturnal masticatory muscle activity and/or snoring can serve as initial indicators of OSA. Higher awareness of dentists to such symptoms, particularly among their middle-aged female patients, can prevent a development of harmful conditions associated with OSA.

Mobile Heart Rate Variability Biofeedback Improves Autonomic Activation and Subjective Sleep Quality of Healthy Adults – A Pilot Study

Objective

Restorative sleep is associated with increased autonomous parasympathetic nervous system activity that might be improved by heart rate variability-biofeedback (HRV-BF) training. Hence the aim of this study was to investigate the effect of a four-week mobile HRV-BF intervention on the sleep quality and HRV of healthy adults.

Methods

In a prospective study, 26 healthy participants (11 females; mean age: 26.04 ± 4.52 years; mean body mass index: 23.76 ± 3.91 kg/m²) performed mobile HRV-BF training with 0.1 Hz breathing over four weeks, while sleep quality, actigraphy and HRV were measured before and after the intervention.

Results

Mobile HRV-BF training with 0.1 Hz breathing improved the subjective sleep quality in healthy adults [t(24) = 4.9127, p ≤ 0.001, d = 0.99] as measured by the Pittsburgh Sleep Quality Index. In addition, mobile HRV-BF training with 0.1 Hz breathing was associated with an increase in the time and frequency domain parameters SDNN, Total Power and LF after four weeks of intervention. No effect was found on actigraphy metrics.

Conclusions

Mobile HRV-BF intervention with 0.1 Hz breathing increased the reported subjective sleep quality and may enhance the vagal activity in healthy young adults. HRV-BF training emerges as a promising tool for improving sleep quality and sleep-related symptom severity by means of normalizing an impaired autonomic imbalance during sleep.