Prognosis and cardiovascular morbidity and mortality in prospective study of hypertensive patients with obstructive sleep apnea syndrome in St Petersburg, Russia

10-Year Risk for Cardiovascular Disease Associated with COMISA (Co-Morbid Insomnia and Sleep Apnea) in Hypertensive Subjects

Due to the few studies available, this study aimed to investigate the 10-year risk for cardiovascular disease (CVD) associated with COMISA (co-morbid insomnia and sleep apnea) in hypertensive subjects. Clinical data of 1009 hypertensive subjects extracted from the Sleep Laboratory database were analyzed. Framingham Risk Score ≥ 10% was used as a cut-off to identify hypertensive subjects with high 10-year risk for CVD. The association between 10-year risk for CVD and COMISA was investigated using logistic regression analyses. 65.3% of hypertensive subjects from our sample presented a high 10-year risk for CVD. After controlling for major confounding factors, multivariate logistic regression analyses demonstrated that unlike its components present separately, COMISA was significantly associated with high 10-year risk for CVD in hypertensive subjects (OR 1.88, 95% CI 1.01-3.51). In this study, we have demonstrated that the negative synergy between obstructive sleep apnea syndrome and insomnia disorder seems to play a central role in the 10-year risk for CVD in hypertensive subjects, which seems to indicate that the establishment of a systematic research and an adapted treatment of COMISA could open new perspectives to promote a better cardiovascular outcome in this specific subgroup of patients.

Sudden death in individuals with obstructive sleep apnoea: a systematic review and meta-analysis

Objectives

Over 1 billion individuals worldwide experience some form of sleep apnoea, and this number is steadily rising. Obstructive sleep apnoea (OSA) can negatively influence one’s quality of life and potentially increase mortality risk. However, the association between OSA and mortality has not been reliably estimated. This meta-analysis estimates the risk of all-cause and cardiovascular mortality in individuals with OSA.

Design

Systematic review and meta-analysis.

Data sources

MEDLINE, Cochrane Library, Scopus and Joanna Briggs Institute Evidence-Based Practice databases were searched from inception through 1 January 2020.

Eligibility criteria for selecting studies

We included observational studies assessing the association of sudden deaths in individuals with and without OSA.

Data extraction and synthesis

Two independent reviewers (AES and ESH) extracted data and assessed the risk of bias using the Newcastle-Ottawa Scale quality assessment tool. Data were pooled using the random-effects models and reported as risk ratios (RRs) with 95% CIs. Heterogeneity was quantified with I² statistic.

Results

We identified 22 observational studies (n=42 099 participants). The mean age was 62 years and 64% were men. OSA was associated with all-cause sudden death (RR=1.74, 95% CI: 1.44 to 2.10, I²=72%) and cardiovascular mortality (RR=1.94, 95% CI: 1.39 to 2.70, I²=32%). A marginally significant dose–response relationship between severity of OSA and the risk of death was observed (p for interaction=0.05): mild OSA (RR=1.16, 95% CI: 0.70 to 1.93), moderate OSA (RR=1.72, 95% CI: 1.11 to 2.67) and severe OSA (RR=2.87, 95% CI: 1.70 to 4.85). Meta-regression analysis showed that older age was a significant contributing factor in the relationship between OSA and mortality. The median study methodological quality was considered high.

Conclusions

OSA is a significant risk factor for all-cause mortality and cardiac mortality. Prevention and treatment strategies to optimise survival and quality of life in individuals with OSA are urgently needed.

PROSPERO registration number

CRD42020164941.

[Risk factors for obstructive sleep apnea in socio-demographic groups of the population of Chuvashia]

OBJECTIVE

To study risk factors (RF) of obstructive sleep apnea syndrome (OSAS) in the socio-demographic groups of the population of Chuvashia.

MATERIALS AND METHODS

An anonymous survey included 2161 residents of Chuvashia (1007 men, 1154 women), aged from 18 to 70 years, average 36.5±13.8 years). Of all included people, 1547 (71.6%) lived in urban settlements, 614 (28.4%) in rural settlements. Exclusion criteria were those under the age of 18 and over 70. Body mass index (BMI) of more than 35 kg/m², neck circumference of more than 43 cm for men or more than 37 cm for women, snoring, fatigue/drowsiness during the day, respiratory arrest in sleep and high blood pressure (BP) were considered as SOAS RF. The likelihood of OSAS was determined by the Lausanne NoSAS (Neck circumference, Obesity, Snoring, Age, Sex) test.

RESULTS

RF OSAS were present in 63.4% of respondents. 2.4% of respondents had a BMI of more than 35 kg/m², 162% had a large neck circumference. Snoring was detected in 24.4%, fatigue/drowsiness during the day in 42.2%, respiratory arrest in sleep in 8.1%, increased BP in 19.7%. In men, compared with women, the number of respondents with a high BMI, snoring, and respiratory failure in a dream was significantly larger; women with a large neck size and complaints of fatigue/drowsiness prevailed. The rural residents had more RF OSAS, including higher BMI, large neck circumference and snoring. The probability of OSAS according to the NoSAS score was 13.65%, including 21.35% of men and 6.93% of women, 11.38% of urban- and 19.38% of rural residents. Multivariate regression analysis showed that the OSAS prediction model included gender, age, BMI, the RF sum of four questions from the questionnaire, neck circumference and level of education with a probability of 99.99%.

CONCLUSION

RF OSAS are widespread in the population of Chuvashia, which requires intensification of preventive measures to minimize them and the development of somnological service in the Republic.

Combined effect of work stress and impaired sleep on coronary and cardiovascular mortality in hypertensive workers: The MONICA/KORA cohort study

BACKGROUND

Although work stress and impaired sleep are established risk factors for cardiovascular disease (CVD) among healthy individuals, their impact on hypertensive workers is largely unknown.

DESIGN

Prospective cohort study design.

METHODS

Hypertensive workers (N = 1959), derived from the population-based MONICA/KORA study in Southern Germany, who were free of any cardiovascular disease and diabetes were interviewed at baseline for work stress (high demand plus low control) and impaired sleep (difficulties falling asleep and/or maintaining sleep). Hazard ratios and 95% confidence intervals (CIs) were estimated by multivariate Cox proportional hazards models with adjustment for relevant covariates.

RESULTS

During a mean follow-up of 17.8 years covering 34,900 person-years, 134 fatal CVD and 73 coronary heart disease (CHD) events were observed. In comparison to participants with low work stress and non-impaired sleep, participants with work stress (hazard ratio (HR) 1.56, 95% CI 0.81-2.98), or impaired sleep (HR 1.76, 95% CI 0.96-3.22) had an increased risk of CVD, while participants with both work stress and impaired sleep had the highest risk of CVD mortality (HR 2.94, 95% CI 1.18-7.33). Participants with both risk conditions had an absolute CVD mortality risk of 7.13 cases per 1000 person-years in comparison to 3.05 cases per 1000-person years in the reference group. Similar risk patterns were found for CHD mortality.

CONCLUSIONS

Our findings add a new piece of evidence that work stress together with impaired sleep increase risk of coronary and cardiovascular mortality in hypertensive workers.

An Official American Thoracic Society Research Statement: Impact of Mild Obstructive Sleep Apnea in Adults

BACKGROUND

Mild obstructive sleep apnea (OSA) is a highly prevalent disorder in adults; however, whether mild OSA has significant neurocognitive and cardiovascular complications is uncertain.

OBJECTIVES

The specific goals of this Research Statement are to appraise the evidence regarding whether long-term adverse neurocognitive and cardiovascular outcomes are attributable to mild OSA in adults, evaluate whether or not treatment of mild OSA is effective at preventing or reducing these adverse neurocognitive and cardiovascular outcomes, delineate the key research gaps, and provide direction for future research agendas.

METHODS

Literature searches from multiple reference databases were performed using medical subject headings and text words for OSA in adults as well as by hand searches. Pragmatic systematic reviews of the relevant body of evidence were performed.

RESULTS

Studies were incongruent in their definitions of "mild" OSA. Data were inconsistent regarding the relationship between mild OSA and daytime sleepiness. However, treatment of mild OSA may improve sleepiness in patients who are sleepy at baseline and improve quality of life. There is limited or inconsistent evidence pertaining to the impact of therapy of mild OSA on neurocognition, mood, vehicle accidents, cardiovascular events, stroke, and arrhythmias.

CONCLUSIONS

There is evidence that treatment of mild OSA in individuals who demonstrate subjective sleepiness may be beneficial. Treatment may also improve quality of life. Future research agendas should focus on clarifying the effect of mild OSA and impact of effective treatment on other neurocognitive and cardiovascular endpoints as detailed in the document.

Obstructive Sleep Apnea Syndrome is Associated with Metabolic Syndrome among Adolescents and Youth in Beijing: data from Beijing Child and Adolescent Metabolic Syndrome Study

Background:

Obstructive sleep apnea (OSA) syndrome has a negative impact on the health of millions of adolescents and youth. The aim of this study was to evaluate the associations of OSA syndrome with obesity and cardiometabolic risk factors among adolescents and youth at risk for metabolic syndrome (MS).

Methods:

A total of 558 subjects aged 14–28 years were recruited from the Beijing Child and Adolescent Metabolic Syndrome Study. Each underwent a 2-h oral glucose tolerance test (OGTT), echocardiography, and liver ultrasonography. Anthropometric measures, blood levels of glucose, lipids, and liver enzymes were assessed. Subjects with high or low risk for OSA were identified by Berlin Questionnaire (BQ).

Results:

Among the subjects in obesity, 33.7% of whom were likely to have OSA by BQ. Subjects with high risk for OSA had higher neck and waist circumference and fat mass percentage compared to those with low risk for OSA (P < 0.001). Moreover, significant differences in levels of lipids, glucose after OGTT, and liver enzymes, as well as echocardiographic parameters were found between the two groups with high or low risk for OSA (P < 0.05). The rates of nonalcoholic fatty liver disease (71.0% vs. 24.2%), MS (38.9% vs. 7.0%), and its components in high-risk group were significantly higher than in low-risk group.

Conclusions:

The prevalence of OSA by BQ was high in obese adolescents and youth. A high risk for OSA indicates a high cardiometabolic risk. Mechanisms mediating the observed associations require further investigation.

Obstructive sleep apnoea and risks of all-cause mortality: preliminary evidence from prospective cohort studies

PURPOSE

A meta-analysis of prospective cohort studies was conducted to clarify the association between obstructive sleep apnoea (OSA) and future risk of all-cause mortality.

METHODS

Eligible studies were identified by searching the PubMed and EMBASE databases up to July 2015. Pooled hazard ratios (HRs) and their corresponding 95 % confidence intervals (CIs) were calculated to estimate the association between OSA and risk of all-cause mortality. Sources of heterogeneity were identified by subgroup and meta-regression analyses.

RESULTS

Twelve prospective cohort studies involving 34,382 participants were included in this meta-analysis. The pooled HR of all-cause mortality was 1.262 (95 % CI 1.093-1.431) with significant heterogeneity. Subgroup analyses indicated that the pooled HRs of all-cause mortality in patients with mild, moderate and severe OSA were 0.945 (95 % CI 0.810-1.081), 1.178 (95 % CI 0.978-1.378) and 1.601 (95 % CI 1.298-1.902), respectively. OSA severity could be a possible sources of heterogeneity. Existing publication bias produced a minor contribution to effect size.

CONCLUSION

Severe, but not mild to moderate, OSA is significantly associated with increased risk of all-cause mortality.

A Cost-Effectiveness Analysis of Surgery for Middle-Aged Men with Severe Obstructive Sleep Apnea Intolerant of CPAP

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is associated with increased cardiovascular morbidity and mortality. Conventional OSA therapy necessitates indefinite continuous positive airway pressure (CPAP). Although CPAP is an effective treatment modality, up to 50% of OSA patients are intolerant of CPAP. We explore whether surgical modalities developed for those intolerant of CPAP are cost-effective.

METHODS

We construct a lifetime semi-Markov model of OSA that accounts for observed increased risks of stroke, cardiovascular disease, and motor vehicle collisions for a 50-year-old male with untreated severe OSA. Using this model, we compare the cost-effectiveness of (1) no treatment, (2) CPAP only, and (3) CPAP followed by surgery (either palatopharyngeal reconstructive surgery [PPRS] or multilevel surgery [MLS]) for those intolerant to CPAP.

RESULTS

Compared with the CPAP only strategy, CPAP followed by PPRS (CPAP-PPRS) adds 0.265 quality adjusted life years (QALYs) for an increase of $2,767 (discounted 2010 dollars) and is highly cost effective with an incremental cost-effectiveness ratio (ICER) of $10,421/QALY for a 50-year-old male with severe OSA. Compared to a CPAP-PPRS strategy, the CPAP-MLS strategy adds 0.07 QALYs at an increase of $6,213 for an ICER of $84,199/QALY. The CPAP-PPRS strategy appears cost-effective over a wide range of parameter estimates.

CONCLUSIONS

Palatopharyngeal reconstructive surgery appears cost-effective in middle-aged men with severe OSA intolerant of CPAP. Further research is warranted to better define surgical candidacy as well as short-term and long-term surgical outcomes.

COMMENTARY

A commentary on this article appears in this issue on page 509.

All-cause mortality from obstructive sleep apnea in male and female patients with and without continuous positive airway pressure treatment: a registry study with 10 years of follow-up

BACKGROUND

More information is needed about the effect on mortality of continuous positive airway pressure (CPAP) in patients with obstructive sleep apnea (OSA), especially in women.

METHODS

We employed a historical cohort study design, using data from 25,389 patients with a diagnosis of OSA selected from the Danish National Patient Registry for the period 1999-2009. We used Cox proportional hazard function to evaluate the all-cause mortality from OSA in middle-aged and elderly males and females who were treated, or not, with CPAP.

RESULTS

Female OSA patients had a lower mortality than males, irrespective of whether they received CPAP treatment. CPAP treatment improved survival, as illustrated by the hazard ratio of 0.62 (P<0.001). This effect was dependent on gender: CPAP had no significant effect on 20- to 39-year-old males and females, but the overall mortality in this age group was small. Survival was increased by CPAP in 40- to 59-year-old and ≥60-year-old males, but no such effect was observed in females. Positive predictors of survival were young age, female gender, higher educational level, and low 3-year prior comorbidity as estimated by the Charlson Comorbidity Index. Negative predictors for survival were male gender, age ≥60 years, no CPAP treatment, prior comorbidity, and low educational level.

CONCLUSION

CPAP therapy is associated with reduced all-cause mortality in middle-aged and elderly males, but no significant effect was found in females.

New insights into the management of rhythm and conduction disorders after acute myocardial infarction

PATIENT

Male, 53 FINAL DIAGNOSIS: Myocardial infarction Symptoms: Chest pain • tachycardia

MEDICATION

- Clinical Procedure: - Specialty: Cardiology.

OBJECTIVE

Challenging differential diagnosis.

BACKGROUND

Comorbidities, including obesity and sleep-breathing disorders, can adversely influence outcomes in acute myocardial infarction (AMI), and should be considered in diagnosis and treatment administration.

CASE REPORT

The case demonstrates the difficulties of treating a middle-aged Caucasian patient with multiple comorbidities that could be overcome by a personalized approach and evaluation of concomitant sleep-breathing disorders (by polysomnography study). Diagnosis and treatment of sleep apnea by positive airway pressure (PAP therapy) played a pivotal role in heart rate and rhythm control.

CONCLUSIONS

In this case, effective PAP therapy enabled titration of antiarrhythmic drugs (to maximal doses) to achieve heart rate control and to eliminate severe ventricular tachyarrhythmias and contributed to the better recovery in a post-AMI patient with left ventricular systolic dysfunction.

Combined bipolar radiofrequency surgery of the tongue base and uvulopalatopharyngoplasty for obstructive sleep apnea

INTRODUCTION

The aim of the study was to investigate the effectiveness of combined bipolar radiofrequency surgery of the tongue base (RFBT) and uvulopalatopharyngoplasty (UPPP) in a single session for obstructive sleep apnea and whether this combination is safe and well tolerated.

MATERIAL AND METHODS

Seventy-nine patients with obstructive sleep apnea and both palatal and retroglossal obstruction underwent UPPP with bipolar RFBT. The control group consisted of 35 patients treated by UPPP alone.

RESULTS

The apnea-hypopnea index significantly decreased from 28.7 to 14.1. The oxygen desaturation index decreased from 15.1 to 10.3. Mean oxygen saturation was unchanged. Subjectively, the Epworth Sleepiness Scale was significantly improved from 10.6 to 7.3, and the snoring level decreased from 8.4 to 6.0. The overall treatment success rate increased from 41.9% for UPPP alone to 51.7% for UPPP + RFBT. No serious adverse events occurred. Two patients had postoperative bleeding from the tonsillar bed after UPPP. Four patients had ulceration of the base of the tongue after RFBT with spontaneous cure. One patient had a taste change in half of the tongue that resolved within two months.

CONCLUSIONS

Combined bipolar RFBT and UPPP in a single session is well tolerated and safe surgery in the treatment of obstructive sleep apnea. It is effective in reducing respiratory parameters and subjective symptoms of obstructive sleep apnea. Further advantages are a single session, simple feasibility, bipolar technique and short time of the procedure.

Is obstructive sleep apnea associated with cardiovascular and all-cause mortality?

Background

Studies have reported inconsistent findings regarding the association between obstructive sleep apnea (OSA) and future risks of cardiovascular and all-cause mortality. We conducted a meta-analysis to investigate whether OSA is an independent predictor for future cardiovascular and all-cause mortality using prospective observational studies.

Methods

Electronic literature databases (Medline and Embase) were searched for prospective observational studies published prior to December 2012. Only observational studies that assessed baseline OSA and future risk of cardiovascular and all-cause mortality were selected. Pooled hazard risk (HR) and corresponding 95% confidence intervals (CI) were calculated for categorical risk estimates. Subgroup analyses were based on the severity of OSA.

Results

Six studies with 11932 patients were identified and analyzed, with 239 reporting cardiovascular mortality, and 1397 all-cause mortality. Pooled HR of all-cause mortality was 1.19 (95% CI, 1.00 to 1.41) for moderate OSA and 1.90 (95% CI, 1.29 to 2.81) for severe OSA. Pooled HR of cardiovascular mortality was 1.40 (95% CI, 0.77 to 2.53) for moderate OSA and 2.65 (95% CI, 1.82 to 3.85) for severe OSA. There were no differences in cardiovascular mortality in continuous positive airway pressure (CPAP) treatment compared with healthy subjects (HR 0.82; 95% CI, 0.50 to 1.33).

Conclusions

Severe OSA is a strong independent predictor for future cardiovascular and all-cause mortality. CPAP treatment was associated with decrease cardiovascular mortality.

Effect of CPAP treatment on endothelial function and plasma CRP levels in patients with sleep apnea

BACKGROUND

Continuous positive airway pressure (CPAP) is the most effective method for treating obstructive sleep apnea syndrome (OSAS) and alleviating symptoms. Improved sleep quality with effective CPAP therapy might also contribute to attenuated systemic inflammation and improved endothelial function, with subsequent reduction of cardiovascular risk. The aim of this study was to assess the effect of 3-month CPAP therapy on brachial artery flow-mediated dilation (FMD) and plasma C-reactive protein (CRP) levels in patients with OSAS.

MATERIAL/METHODS

Our study group consisted of 38 male patients with no prior history of cardiovascular disease. Twenty patients with an Apnea-Hypopnea Index (AHI) ≥15 were assigned to receive CPAP treatment and 18 subjects with an AHI<5 were included in the control group. Six patients failed to comply with the CPAP treatment. Measurement of FMD and blood analysis was performed at baseline and 3 months after CPAP therapy.

RESULTS

Baseline FMD values were negatively correlated with age, BMI, AHI, DSI,% of time <90% Sa02, and CRP (p<0.05). Plasma CRP values were positively correlated with BMI, AHI, DSI and% of time <90% Sa02 (p<0.05). In the group of patients who complied with the CPAP treatment, there was a significant increase in the FMD values (9.18 ± 0.55 vs. 6.27 ± 0.50) and a decrease in the levels of CRP (0.67 ± 0.15 vs. 0.84 ± 0.18) (p<0.05).

CONCLUSIONS

Appropriate CPAP therapy improved both CRP and FMD values, suggesting its potentially beneficial role in reducing cardiovascular risk in OSAS patients.

Neck circumference, metabolic syndrome and obstructive sleep apnea syndrome; evaluation of possible linkage

Background

This study was performed to evaluate neck circumference (NC) and metabolic syndrome (MS) parameters in severe and non-severe (mild-moderate) obstructive sleep apnea syndrome (OSAS) patients according to apnea-hypopnea index (AHI).

Material/Method

We enrolled 44 patients diagnosed with OSAS based on overnight polysomnography. The diagnosis of OSAS was based on AHI. Apnea is a pause of airflow for more than 10 seconds. and hypopnea is a decrease of airflow for more than 10 seconds and oxygen desaturation of 4% or greater. AHI score. per hour; below 5 normal. 5–29 mild-moderate. 30 and above were grouped as severe OSAS. Height. weight. neck circumference (NC). waist circumference (WC) and body mass index (BMI) of the patients were measured. MS was diagnosed by the Adult Treatment Panel (ATP) III criteria (≥3 of the following abnormalities): 1) WC ≥94 cm for males, ≥80 cm for females; 2) arterial blood pressure ≥130/85 mmHg; 3) fasting blood glucose ≥100 mg/dl; 4) high density lipoprotein (HDL) cholesterol <40 mg/dl in man, <50 mg/dl in women; 5) triglycerides ≥150 mg/dl.

Results

Mean BMI and NC were higher in severe OSAS patients compared to non-severe patients (p=0.021. p<0.001). According to ATP III criteria. 64% of severe and 61.1% of non-severe OSAS patients were MS (p=0.847). A logistic regression model displayed an association with NC as a risk factor for severe OSAS (p=0.01). but not with MS.

Conclusions

In this study. NC in severe OSAS patients was significantly higher than in non-severe OSAS patients. The prevalence of metabolic syndrome was not correlated with OSAS severity. NC is an independent risk factor for severe OSAS.