Prevalence of Cardiovascular Events and Their Risk Factors in Patients With Chronic Obstructive Pulmonary Disease and Obstructive Sleep Apnea Overlap Syndrome

Factors associated with risk analysis for asymptomatic left ventricular diastolic dysfunction in nondialysis patients with chronic kidney disease

Heart failure (HF) constitutes a major determinant of outcome in chronic kidney disease (CKD) patients. The main pattern of HF in CKD patients is preserved ejection fraction (HFpEF), and left ventricular diastolic dysfunction (LVDD) is a frequent pathophysiological mechanism and specific preclinical manifestation of HFpEF. Therefore, exploring and intervention of the factors associated with risk for LVDD is of great importance in reducing the morbidity and mortality of cardiovascular disease (CVD) complications in CKD patients. We designed this retrospective cross-sectional study to collect clinical and echocardiographic data from 339 nondialysis CKD patients without obvious symptoms of HF to analyze the proportion of asymptomatic left ventricular diastolic dysfunction (ALVDD) and its related factors associated with risk by multivariate logistic regression analysis. Among the 339 nondialysis CKD patients, 92.04% had ALVDD. With the progression of CKD stage, the proportion of ALVDD gradually increased. The multivariate logistic regression analysis revealed that increased age (OR 1.237; 95% confidence interval (CI) 1.108-1.381, per year), diabetic nephropathy (DN) and hypertensive nephropathy (HTN) (OR 25.000; 95% CI 1.355-48.645, DN and HTN vs chronic interstitial nephritis), progression of CKD stage (OR 2.785; 95% CI 1.228-6.315, per stage), increased mean arterial pressure (OR 1.154; 95% CI 1.051-1.268, per mmHg), increased urinary protein (OR 2.825; 95% CI 1.484-5.405, per g/24 h), and low blood calcium (OR 0.072; 95% CI 0.006-0.859, per mmol/L) were factors associated with risk for ALVDD in nondialysis CKD patients after adjusting for other confounding factors. Therefore, dynamic monitoring of these factors associated with risk, timely diagnosis and treatment of ALVDD can delay the progression to symptomatic HF, which is of great importance for reducing CVD mortality, and improving the prognosis and quality of life in CKD patients.

Multidimensional phenotyping to distinguish among distinct obstructive sleep apnea, chronic obstructive pulmonary disease, and overlap syndrome phenotypes

OBJECTIVE/BACKGROUND

Chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA) and their comorbid association called Overlap Syndrome (OS) are frequent chronic diseases with high individual and societal burdens. Precise descriptions of the respective symptoms, comorbidities, and medications associated with these three conditions are lacking. We used a multidimensional phenotyping approach to identify relevant phenotypes characterizing these 3 disorders.

PATIENTS/METHODS

308 patients with OSA, COPD and OS were prospectively assessed using a combination of body shape measurements and multidimensional questionnaires evaluating sleep, fatigue, depression and respiratory symptoms. Comorbidities and medications were confirmed by physicians. Patients made home blood pressure self-measurements using a connected wearable device to identify undiagnosed or uncontrolled hypertension.

RESULTS

Three distinct relevant phenotypes were identified. OSA patients were round in shape with a balanced waist-to-hip ratio, frequent witnessed apneas, nocturia, daytime sleepiness, depression, and high diastolic blood pressure. COPD patients had a thinner body shape with a high waist-to-hip ratio, complained mainly of fatigue, and exhibited a higher resting heart rate. OS patients were round in shape with a balanced waist-to-hip ratio, reported little sleepiness and depression, but had impaired sleep and the highest rate of cardio-metabolic comorbidities. Diminished fitness-to-drive was most apparent in patients with OSA and OS. Home blood pressure measurements identified undiagnosed hypertension in 80 % of patients and in nearly 80 % of those with hypertension it was uncontrolled by their current medications.

CONCLUSIONS

Our systematic multidimensional phenotyping approach identified distinct body shapes, symptoms, and comorbidity profiles among patients with OSA, COPD, and OS.

The clinical and hemodynamic characteristics of pulmonary hypertension in patients with OSA-COPD overlap syndrome

BACKGROUND

Our study aimed to assess the clinical and hemodynamic characteristics of pulmonary hypertension (PH) in patients with overlapping obstructive sleep apnea (OSA) and chronic obstructive pulmonary disease (COPD), referred to OSA-COPD overlap syndrome (OS).

METHODS

We enrolled a total of 116 patients with OS, COPD, or OSA who underwent right heart catheterization (RHC) due to suspected PH. We conducted a retrospective analysis of the clinical and hemodynamic characteristics of these patients.

RESULTS

Among the three groups (OS group, n = 26; COPD group, n = 36; OSA group, n = 54), the prevalence of PH was higher in the OS group (n = 17, 65.4%)compared to OSA group (n = 26,48.1%) and COPD group (n = 20,55.6 %). Among three groups with PH, the superior vena cava pressure (CVP) and right ventricular pressure (RAP) were higher in the OS group than in the OSA group (P < 0.05). Patients in the OS and COPD groups had higher pulmonary artery wedge pressure (PAWP) than in the OSA group (14.88 ± 4.79 mmHg, 13.45 ± 3.68 mmHg vs. 11.00 ± 3.51 mmHg, respectively, P < 0.05). OS patients with PH exhibited higher respiratory event index (REI), time spent with SpO2 <90%, oxygen desaturation index (ODI), minimal SpO2 (MinSpO2) and mean SpO2 (MSpO2) compared to OS patients without PH. After adjusting for potential covariates, we found that MinSpO2 (OR 0.937, 95 % CI 0.882-0.994, P = 0.032), MSpO2 (OR 0.805, 95% CI 0.682-0.949, P = 0.010), time spent with SpO2 <90% (OR 1.422, 95% CI 1.137-1.780, P = 0.002), and FEV1 % pred (OR 0.977, 95 % CI 0.962-0.993, P = 0.005) were related to the development of PH.

CONCLUSIONS

Patients with OS showed higher prevalence of PH, along with higher PAWP, CVP and RAP. Worse nocturnal hypoxemia was found in OS patients with PH.

Defining the role of exertional hypoxemia and pulmonary vasoconstriction on lung function decline, morbidity, and mortality in patients with chronic obstructive lung disease - the PROSA study: rationale and study design

BACKGROUND

Chronic obstructive lung disease (COPD) has diverse molecular pathomechanisms and clinical courses which, however, are not fully mirrored by current therapy. Intermittent hypoxemia is a driver of lung function decline and poor outcome, e.g., in patients with concomitant obstructive sleep apnea. Transient hypoxemia during physical exercise has been suggested to act in a similar manner. The PROSA study is designed to prospectively assess whether the clinical course of COPD patients with or without exertional desaturation differs, and to address potential pathophysiological mechanisms and biomarkers.

METHODS

148 COPD patients (GOLD stage 2-3, groups B or C) will undergo exercise testing with continuous pulse oximetry. They will be followed for 36 months by spirometry, echocardiography, endothelial function testing, and biomarker analyses. Exercise testing will be performed by comparing the 6-min walk test (6MWT), bicycle ergometry, and a 15-sec breath-hold test. Exertional desaturation will be defined as SpO2 < 90% or delta-SpO2 ≥ 4% during the 6MWT. The primary endpoint will be the rate of decline of FEV1(LLN) between COPD patients with and without exertional desaturation.

DISCUSSION

The PROSA Study is an investigator-initiated prospective study that was designed to prove or dismiss the hypothesis that COPD patients with exertional desaturation have a significantly more rapid rate of decline of lung function as compared to non-desaturators. A 20% difference in the primary endpoint was considered clinically significant; it can be detected with a power of 90%. If the primary endpoint will be met, exercise testing with continuous pulse oximetry can be used as a ubiquitously available, easy screening tool to prospectively assess the risk of rapid lung function decline in COPD patients at an early disease stage. This will allow to introduce personalized, risk-adapted therapy to improve COPD outcome in the long run. PROSA is exclusively funded by public funds provided by the European Research Council through an ERC Advanced Grant. Patient recruitment is ongoing; the PROSA results are expected to be available in 2028.

TRIAL REGISTRATION

The PROSA Study has been prospectively registered at clinicaltrials.gov (register no. NCT06265623, dated 09.02.2024).

Outcomes of coronary artery bypass grafting (CABG) in patients with OSA-COPD overlap syndrome versus COPD alone: an analysis of US Nationwide Inpatient Sample

BACKGROUND

Obstructive sleep apnea (OSA) and chronic obstructive pulmonary disease (COPD) are associated with unfavorable outcomes following coronary artery bypass grafting (CABG). The purpose of this study was to compare in-hospital outcomes of patients with COPD alone versus OSA-COPD overlap after CABG.

METHODS

Data of adults ≥ 18 years old with COPD who received elective CABG between 2005 and 2018 were extracted from the US Nationwide Inpatient Sample (NIS). Patients were divided into two groups: with OSA-COPD overlap and COPD alone. Propensity score matching (PSM) was employed to balance the between-group characteristics. Logistic and linear regression analyses determined the associations between study variables and inpatient outcomes.

RESULTS

After PSM, data of 2,439 patients with OSA-COPD overlap and 9,756 with COPD alone were analyzed. After adjustment, OSA-COPD overlap was associated with a significantly increased risk of overall postoperative complications (adjusted odd ratio [aOR] = 1.12, 95% confidence interval [CI]: 95% CI: 1.01-1.24), respiratory failure/prolonged mechanical ventilation (aOR = 1.27, 95%CI: 1.14-1.41), and non-routine discharge (aOR = 1.16, 95%CI: 1.03-1.29), and AKI (aOR = 1.14, 95% CI: 1.00-1.29). Patients with OSA-COPD overlap had a lower risk of in-hospital mortality (adjusted odd ratio [aOR] = 0.53, 95% CI: 0.35-0.81) than those with COPD only. Pneumonia or postoperative atrial fibrillation (AF) risks were not significantly different between the 2 groups. Stratified analyses revealed that, compared to COPD alone, OSA-COPD overlap was associated with increased respiratory failure/prolonged mechanical ventilation risks among patients ≥ 60 years, and both obese and non-obese subgroups. In addition, OSA-COPD overlap was associated with increased risk of AKI among the older and obese subgroups.

CONCLUSION

In US adults who undergo CABG, compared to COPD alone, those with OSA-COPD are at higher risks of non-routine discharge, AKI, and respiratory failure/prolonged mechanical ventilation, but a lower in-hospital mortality. No increased risk of AF was noted.

The Overlap Syndrome: A Combination of Chronic Obstructive Pulmonary Disease and Obstructive Sleep Apnea

Chronic obstructive pulmonary disease (COPD) is a severe lung disease that results in persistent and progressively worsening airflow obstruction due to abnormalities in the airway and alveoli. Obstructive sleep apnea (OSA) is a critical condition characterized by obstructive apneas, hypopneas, and respiratory effort-related arousals. These events occur due to the repetitive collapse of the upper airway during sleep, and it is essential to address this condition. These two conditions, when co-occur, are known as overlap syndrome (OS), which is associated with a higher likelihood of morbidity and mortality compared to either condition alone. Effective management of overlap syndrome is critical to maintain normal oxygen levels during sleep and reduce the incidence of hypoxemia and hypoventilation while improving sleep quality. Positive pressure ventilation is a standard technique used to effectively lower hospitalizations, emergency room visits, moderate and severe exacerbations, and related healthcare expenses in patients diagnosed with COPD and OSA. Despite the lack of literature on overlap syndrome, it is imperative to understand that this condition requires prompt and effective management to prevent further complications. Therefore, this review provides a detailed discussion highlighting the importance of proactive measures to manage overlap syndrome.

Is COPD the Determinant Factor for Myocardial Injury and Cardiac Wall Stress in OSA Patients?

Background and Objectives: Evidence shows that COPD-OSA overlap syndrome (OS) is more frequently accompanied by cardiovascular disease (CVD) in comparison to either disease alone. The aim of the study was to explore whether patients with OS have a higher burden of subclinical myocardial injury and wall stress compared with OSA patients. Materials and Methods: Consecutive patients, without established CVD, underwent polysomnography and pulmonary function testing, due to suspected sleep-disordered breathing. An equal number of patients with OS (n = 53, with an apnea hypopnea index (AHI) > 5/h and FEV1/FVC < 0.7) and patients with OSA (n = 53, AHI > 5/h and FEV1/FVC > 0.7) were included in the study. The detection of asymptomatic myocardial injury and wall stress was performed via the assessment of serum high-sensitivity cardiac troponin T (hs-cTnT) and N-terminal pro-B-type natriuretic peptide (NT-proBNP), respectively. Results: OS patients were older (p < 0.001) and had worse hypoxemic parameters, namely average oxyhemoglobin saturation (SpO2) (p = 0.002) and time spent with SpO2 < 90% (p = 0.003) during sleep as well as daytime pO2 (p < 0.001), than patients with OSA. No difference was observed between groups in terms of Epworth Sleepiness Scale (p = 0.432) and AHI (p = 0.587). Both levels of hs-cTnT (14.2 (9.1-20.2) vs. 6.5 (5.6-8.7) pg/mL, p < 0.001) and NT-proBNP (93.1 (37.9-182.5) vs. 19.2 (8.3-35.4) pg/mL, p < 0.001) were increased in OS compared to OSA patients. Upon multivariate linear regression analysis, levels of NT-proBNP and hs-cTnT correlated with age and average SpO2 during sleep. Conclusions: Our study demonstrated higher levels of hs-cTnT and NT-proBNP in OS patients, indicating an increased probability of subclinical myocardial injury and wall stress, compared with OSA individuals.

The Interplay between Obstructive Sleep Apnea, Chronic Obstructive Pulmonary Disease, and Congestive Heart Failure: Time to Collectively Refer to Them as Triple Overlap Syndrome?

BACKGROUND AND OBJECTIVES

Obstructive sleep apnea-hypopnea syndrome (OSAHS) and chronic obstructive pulmonary disease (COPD) are independently linked to an increase in cardiovascular disease (CVD). Only a few studies have been published linking the association between overlap syndrome and congestive heart failure (CHF). This review highlights the interplay between overlap syndrome (OSAHS-COPD) and CHF.

MATERIALS AND METHODS

We thoroughly reviewed published literature from 2005 to 2022 in PubMed, Google Scholar, and Cochrane databases to explore the link between overlap syndrome and cardiovascular outcomes, specifically congestive heart failure.

RESULTS

Research indicates that individuals with overlap syndrome are more likely to develop congestive heart failure than those with COPD or OSA alone. Congestive heart failure is a common comorbidity of overlap syndrome, and it has a two-way connection with sleep-related breathing disorders, which tend to occur together more frequently than expected by chance.

CONCLUSIONS

CHF seems to have a strong relationship with OS. Further research is required to understand the relationship between OS and CHF.

Patient-Reported Outcome Measurements in Patients with COPD-Obstructive Sleep Apnea Overlap Syndrome: Time for Action?

Chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea syndrome (OSA) are common conditions that often coexist [Overlap syndrome (OS)]. OS has important implications in the diagnosis, treatment, and patient outcome of both disorders. Patient-reported outcomes (PROs) are essential to evaluate symptoms, impact of symptoms on activities of daily living, and treatment response. The present review aims to display the potential usefulness of PROs measurements (PROMs) regarding the initial evaluation and treatment of both conditions (COPD and OSA) in OS patients. More specifically, we review PROMs regarding symptoms, mental health indices and health-related quality of life in patients with OS. These PROMs have the potential to add value to clinical research and daily practice in certain aspects that are important to patients.

Chronic obstructive pulmonary disease and obstructive sleep apnoea overlap: co-existence, co-morbidity, or causality?

PURPOSE OF REVIEW

The chronic obstructive pulmonary disease and obstructive sleep apnoea overlap syndrome is associated with higher morbidity and mortality rates than either disease alone. There is evidence of a bidirectional relationship between the two conditions, with the overlap syndrome encompassing a spectrum of clinical phenotypes.

RECENT FINDINGS

This review examines the evidence for the various factors that determine the overlap syndrome, the impact overlap syndrome has on co-morbidities, and implications for diagnosis and treatment.

SUMMARY

The accurate diagnosis of the overlap syndrome is critical given its implications for treatment optimisation and reduction in healthcare utilisation and costs.

Effects of chronic obstructive pulmonary disease on long-term prognosis of patients with coronary heart disease post-percutaneous coronary intervention

BACKGROUND

Chronic obstructive pulmonary disease (COPD) and cardiovascular diseases are often comorbid conditions, their co-occurrence yields worse outcomes than either condition alone. This study aimed to investigate COPD impacts on the five-year prognosis of patients with coronary heart disease (CHD) after percutaneous coronary intervention (PCI).

METHODS

Patients with CHD who underwent PCI in 2013 were recruited, and divided into COPD group and non-COPD group. Adverse events occurring among those groups were recorded during the five-year follow-up period after PCI, including all-cause death and cardiogenic death, myocardial infarction, repeated revascularization, as well as stroke and bleeding events. Major adverse cardiac and cerebral events were a composite of all-cause death, myocardial infarction, repeated revascularization and stroke.

RESULTS

A total of 9843 patients were consecutively enrolled, of which 229 patients (2.3%) had COPD. Compared to non-COPD patients, COPD patients were older, along with poorer estimated glomerular filtration rate and lower left ventricular ejection fraction. Five-year follow-up results showed that incidences of all-cause death and cardiogenic death, as well as major adverse cardiac and cerebral events, for the COPD group were significantly higher than for non-COPD group (10.5% vs. 3.9%, 7.4% vs. 2.3%, and 30.1% vs. 22.6%, respectively). COPD was found under multivariate Cox regression analysis, adjusted for confounding factors, to be an independent predictor of all-cause death [odds ratio (OR) = 1.76, 95% CI: 1.15-2.70, P = 0.009] and cardiogenic death (OR = 2.02, 95% CI: 1.21-3.39, P = 0.007).

CONCLUSIONS

COPD is an independent predictive factor for clinical mortality, in which CHD patients with COPD are associated with worse prognosis than CHD patients with non-COPD.

Risk for Cardiovascular Disease and One-Year Mortality in Patients With Chronic Obstructive Pulmonary Disease and Obstructive Sleep Apnea Syndrome Overlap Syndrome

Background: Patients with chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSAS) overlap syndrome (OS) are thought to be at increased risk for cardiovascular diseases.

Objective: To evaluate the burden of cardiovascular diseases and long-term outcomes in patients with OS.

Methods: This was a retrospective cohort study. The prevalence of cardiovascular diseases and 1-year mortality were compared among patients diagnosed with OS (OS group), COPD alone (COPD group) and OSAS alone (OSAS group), and Cox proportional hazards models were used to assess independent risk factors for all-cause mortality.

Results: Overall, patients with OS were at higher risk for pulmonary hypertension (PH), heart failure and all-cause mortality than patients with COPD or OSAS (all p < 0.05). In multivariate Cox regression analysis, the Charlson comorbidity index (CCI) score [adjusted hazard ratio (aHR): 1.273 (1.050–1.543); p = 0.014], hypertension [aHR: 2.006 (1.005–4.004); p = 0.048], pulmonary thromboembolism (PTE) [aHR: 4.774 (1.335–17.079); p = 0.016] and heart failure [aHR: 3.067 (1.521–6.185); p = 0.002] were found to be independent risk factors for 1-year all-cause mortality.

Conclusion: Patients with OS had an increased risk for cardiovascular diseases and 1-year mortality. More efforts are needed to identify the causal relationship between OS and cardiovascular diseases, promoting risk stratification and the management of these patients.

Burden of Comorbidities in Patients with OSAS and COPD-OSAS Overlap Syndrome

Background and Objectives: Obstructive sleep apnea syndrome (OSAS) and chronic obstructive pulmonary disease (COPD) are usually associated with multi-morbidity. The aim of this study was to retrospectively investigate the prevalence of comorbidities in a cohort of patients with OSAS and COPD-OSAS overlap syndrome (OS) patients and to explore differences between these two groups. Materials and Methods: Included were consecutive OS patients and OSAS patients who had been referred to our sleep laboratory, and were matched in terms of sex, age, BMI, and smoking history. Presence of comorbidities was recorded based on their medical history and after clinical and laboratory examination. Results: The two groups, OS patients (n = 163, AHI > 5/h and FEV₁/FVC < 0.7) and OSAS patients (n = 163, AHI > 5/h, and FEV₁/FVC > 0.7), did not differ in terms of apnea hypopnea index (p = 0.346), and oxygen desaturation index (p = 0.668). Compared to OSAS patients, OS patients had lower average SpO₂ (p = 0.008) and higher sleep time with oxygen saturation <90% (p = 0.002) during sleep, and lower PaO₂ (p < 0.001) and higher PaCO₂ (p = 0.04) in wakefulness. Arterial hypertension was the most prevalent comorbidity for both OS and OSAS, followed by dyslipidemia, cardiovascular disease (CVD) and diabetes. OS was characterized by a higher prevalence of total comorbidities (median (IQR):2 (1–3) vs. 2 (1–2), p = 0.033), which was due to the higher prevalence of CVD (p = 0.016) than OSAS. No differences were observed in other comorbidities. Conclusions: In OS patients, nocturnal hypoxia and impaired gas exchange in wakefulness are more overt, while a higher burden of CVD is observed among them in comparison to sex-, age- and BMI-matched OSAS patients.