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Filchenko I, Duss SB, Salzmann S, Brill AK, Korostovtseva L, Amelina V, Baillieul S, Bernasconi C, Schmidt MH, Bassetti CLA. Early sleep apnea treatment in stroke (eSATIS) - a multicentre, randomised controlled, rater-blinded, clinical trial: The association of post-stroke cognition with sleep-disordered breathing and its treatment. J Sleep Res 2024:e14296. [PMID: 39251407 DOI: 10.1111/jsr.14296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 06/22/2024] [Accepted: 07/13/2024] [Indexed: 09/11/2024]
Abstract
Sleep-disordered breathing (SDB) is linked to cognitive dysfunction. Although SDB is common in stroke patients, the impact of SDB and its early treatment on cognitive functioning after stroke remains poorly investigated. Therefore, we explored the association between SDB and post-stroke cognitive functioning, including the impact of early SDB treatment with adaptive servo-ventilation (ASV) on cognitive recovery from acute event to 3 months post-stroke. We used data from two studies, which included ischaemic stroke patients (n = 131) and no-stroke controls (n = 37) without SDB (apnea-hypopnea index, AHI <5/h) and with SDB (AHI≥20/h). Cognitive functioning was assessed within 7 days and 3 months post-stroke in stroke patients, or at study inclusion in no-stroke control group, respectively. Stroke patients with SDB were randomized to ASV treatment (ASV+) or usual care (ASV-). Linear regression adjusted for main confounders assessed the impact of SDB and its treatment on cognitive recovery. The intention-to-treat analysis did not show significant associations of SDB ASV+ (n = 30) versus SDB ASV- (n = 29) with cognitive recovery. In an exploratory subanalysis, compliant SDB ASV+ (n = 14) versus SDB ASV- showed improvements with ASV in visual memory and cognitive flexibility. Combining the stroke and non-stroke datasets, SDB (n = 85) versus no-SDB (n = 83) was associated with deficits in visual memory and response inhibition independently of stroke. SDB ASV- versus no-SDB (n = 51) was associated with less improvement in visual memory. There was no substantial evidence for benefits of intention-to-treat ASV on cognitive recovery. Exploratory analysis indicated that compliant ASV treatment could benefit visual memory and cognitive flexibility, whereas untreated SDB could contribute to a poor recovery of visual memory.
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Affiliation(s)
- Irina Filchenko
- Department of Neurology, Bern University Hospital (Inselspital) and University of Bern, Bern, Switzerland
- Interdisciplinary Sleep-Wake-Epilepsy Centre, Bern University Hospital (Inselspital) and University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Simone B Duss
- Department of Neurology, Bern University Hospital (Inselspital) and University of Bern, Bern, Switzerland
- Interdisciplinary Sleep-Wake-Epilepsy Centre, Bern University Hospital (Inselspital) and University of Bern, Bern, Switzerland
| | - Saskia Salzmann
- Department of Neurology, Bern University Hospital (Inselspital) and University of Bern, Bern, Switzerland
- Interdisciplinary Sleep-Wake-Epilepsy Centre, Bern University Hospital (Inselspital) and University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
- Division of Neuropaediatrics, Development and Rehabilitation, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anne-Kathrin Brill
- Interdisciplinary Sleep-Wake-Epilepsy Centre, Bern University Hospital (Inselspital) and University of Bern, Bern, Switzerland
- Department for Pulmonary Medicine, Allergology and Clinical Immunology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lyudmila Korostovtseva
- Laboratory of Somnology, Almazov National Medical Research Centre, Sankt-Peterburg, Russia
| | - Valeria Amelina
- Laboratory of Somnology, Almazov National Medical Research Centre, Sankt-Peterburg, Russia
| | - Sébastien Baillieul
- Univ. Grenoble Alpes, Inserm, U1300, CHU Grenoble Alpes, Service Universitaire de Pneumologie Physiologie, Grenoble, France
| | - Corrado Bernasconi
- Department of Neurology, Bern University Hospital (Inselspital) and University of Bern, Bern, Switzerland
- Interdisciplinary Sleep-Wake-Epilepsy Centre, Bern University Hospital (Inselspital) and University of Bern, Bern, Switzerland
| | - Markus H Schmidt
- Department of Neurology, Bern University Hospital (Inselspital) and University of Bern, Bern, Switzerland
- Interdisciplinary Sleep-Wake-Epilepsy Centre, Bern University Hospital (Inselspital) and University of Bern, Bern, Switzerland
| | - Claudio L A Bassetti
- Department of Neurology, Bern University Hospital (Inselspital) and University of Bern, Bern, Switzerland
- Interdisciplinary Sleep-Wake-Epilepsy Centre, Bern University Hospital (Inselspital) and University of Bern, Bern, Switzerland
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Baillieul S, Tamisier R, Gévaudan B, Alexandre S, Detante O, Dauvilliers Y, Bassetti C, Pépin JL, Bailly S. Trajectories of self-reported daytime sleepiness post-ischemic stroke and transient ischemic attack: A propensity score matching study versus non-stroke patients. Eur Stroke J 2024; 9:451-459. [PMID: 38268186 PMCID: PMC11318414 DOI: 10.1177/23969873241227751] [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: 09/20/2023] [Accepted: 01/04/2024] [Indexed: 01/26/2024] Open
Abstract
INTRODUCTION Severe sleep apnea (SA) affects one-third of stroke patients. Sleepiness, one of the cardinal symptoms of SA, negatively impacts functional stroke outcomes. The impact of continuous positive airway pressure (CPAP) on post-stroke sleepiness is poorly described. We aimed to compare through a propensity score matching the trajectories of self-reported sleepiness post-stroke with matched individuals including SA patients adherent or not to CPAP. PATIENTS AND METHODS Sixty five (80.2%) ischemic stroke and 16 (19.8%) TIA patients (median [Q1;Q3] age = 67.0 [58.0;74.0] years, 70.4% male, body mass index [BMI] = 26.1 [24.5;29.8] kg·m-2, admission NIHSS = 3.0 [1.0;5.0]), with polysomnography and an Epworth Sleepiness Scale (ESS) performed within 1 year following stroke and with a follow-up ESS (delay = 236 [147;399] days) were included in the analysis. A 2:1 propensity score matching based on age, gender, BMI, and the apnea-hypopnea index was performed to identify 162 matched individuals referred for SA suspicion, free of stroke or TIA. Multivariable negative binomial regression models were performed to identify the determinants of sleepiness trajectories post-stroke. RESULTS Baseline ESS was comparable between stroke/TIA and matched individuals (median [Q1; Q3] ESS = 7 [4;10] versus 6 [4;10], p = 0.86). The range of improvement in ESS was higher in stroke patients compared to controls (∆ESS = -2 [-4;1] vs -1 [-3;2], p = 0.03). In multivariable analysis, comorbid SA and CPAP treatment did not influence trajectories of sleepiness post-stroke. DISCUSSION AND CONCLUSION Sleepiness improvement was unexpectedly higher in stroke patients compared to matched individuals, with no significant influence of comorbid SA and CPAP on its trajectory. Sleepiness may not be primarily indicative of SA in stroke or TIA patients.
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Affiliation(s)
- Sébastien Baillieul
- Univ. Grenoble Alpes, Inserm, U1300, CHU Grenoble Alpes, Service Universitaire de Pneumologie Physiologie, Grenoble, France
| | - Renaud Tamisier
- Univ. Grenoble Alpes, Inserm, U1300, CHU Grenoble Alpes, Service Universitaire de Pneumologie Physiologie, Grenoble, France
| | - Bastien Gévaudan
- Univ. Grenoble Alpes, Inserm, U1300, CHU Grenoble Alpes, Service Universitaire de Pneumologie Physiologie, Grenoble, France
| | - Sarah Alexandre
- Univ. Grenoble Alpes, Inserm, U1300, CHU Grenoble Alpes, Service Universitaire de Pneumologie Physiologie, Grenoble, France
| | - Olivier Detante
- Neurology Department, Grenoble Alpes University Hospital, Grenoble, France
| | - Yves Dauvilliers
- National Reference Centre for Orphan Diseases Narcolepsy Rare Hypersomnias, Sleep Unit, Department of Neurology, CHU Montpellier, University of Montpellier, Montpellier, France
- Institute for Neurosciences of Montpellier (INM), University of Montpellier, INSERM, Montpellier, France
| | - Claudio Bassetti
- Neurology Department, Inselspital, Bern University Hospital, Switzerland
| | - Jean-Louis Pépin
- Univ. Grenoble Alpes, Inserm, U1300, CHU Grenoble Alpes, Service Universitaire de Pneumologie Physiologie, Grenoble, France
| | - Sébastien Bailly
- Univ. Grenoble Alpes, Inserm, U1300, CHU Grenoble Alpes, Service Universitaire de Pneumologie Physiologie, Grenoble, France
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Sindorf J, Szabo AL, O'Brien MK, Sunderrajan A, Knutson KL, Zee PC, Wolfe L, Arora VM, Jayaraman A. Wireless wearable sensors can facilitate rapid detection of sleep apnea in hospitalized stroke patients. Sleep 2024:zsae123. [PMID: 38814827 DOI: 10.1093/sleep/zsae123] [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: 03/08/2024] [Indexed: 06/01/2024] Open
Abstract
STUDY OBJECTIVES To evaluate wearable devices and machine learning for detecting sleep apnea in patients with stroke at an acute inpatient rehabilitation facility (IRF). METHODS A total of 76 individuals with stroke wore a standard home sleep apnea test (ApneaLink Air), a multimodal, wireless wearable sensor system (ANNE), and a research-grade actigraphy device (ActiWatch) for at least one night during their first week after IRF admission as part of a larger clinical trial. Logistic regression algorithms were trained to detect sleep apnea using biometric features obtained from the ANNE sensors and ground truth apnea rating from the ApneaLink Air. Multiple algorithms were evaluated using different sensor combinations and different apnea detection criteria based on the Apnea-Hypopnea Index (AHI≥5, AHI≥15). RESULTS Seventy-one (96%) participants wore the ANNE sensors for multiple nights. In contrast, only forty-eight participants (63%) could be successfully assessed for OSA by ApneaLink; 28 (37%) refused testing. The best-performing model utilized photoplethysmography (PPG) and finger temperature features to detect moderate-severe sleep apnea (AHI≥15), with 88% sensitivity and a positive likelihood ratio (LR+) of 44.00. This model was tested on additional nights of ANNE data achieving 71% sensitivity (10.14 LR+) when considering each night independently and 86% accuracy when averaging multi-night predictions. CONCLUSIONS This research demonstrates the feasibility of accurately detecting moderate-severe sleep apnea early in the stroke recovery process using wearable sensors and machine learning techniques. These findings can inform future efforts to improve early detection for post-stroke sleep disorders, thereby enhancing patient recovery and long-term outcomes.
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Affiliation(s)
| | - Alison L Szabo
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Megan K O'Brien
- Shirley Ryan AbilityLab, Chicago, IL, USA
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | | | - Kristen L Knutson
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Phyllis C Zee
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Lisa Wolfe
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Vineet M Arora
- University of Chicago School of Medicine, Chicago, IL, USA
| | - Arun Jayaraman
- Shirley Ryan AbilityLab, Chicago, IL, USA
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
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Mohamed B, Yarlagadda K, Self Z, Simon A, Rigueiro F, Sohooli M, Eisenschenk S, Doré S. Obstructive Sleep Apnea and Stroke: Determining the Mechanisms Behind their Association and Treatment Options. Transl Stroke Res 2024; 15:239-332. [PMID: 36922470 DOI: 10.1007/s12975-023-01123-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/02/2023] [Accepted: 01/02/2023] [Indexed: 03/18/2023]
Abstract
Sleep-disordered breathing (SDB) can be a sequela of stroke caused by vascular injury to vital respiratory centers, cerebral edema, and increased intracranial pressure of space-occupying lesions. Likewise, obstructive sleep apnea (OSA) contributes to increased stroke risk through local mechanisms such as impaired ischemic cerebrovascular response and systemic effects such as promoting atherosclerosis, hypercoagulability, cardiac arrhythmias, vascular-endothelial dysfunction, and metabolic syndrome. The impact of OSA on stroke outcomes has been established, yet it receives less attention in national guidelines on stroke management than hyperglycemia and blood pressure dysregulation. Furthermore, whether untreated OSA worsens stroke outcomes is not well-described in the literature. This scoping review provides an updated investigation of the correlation between OSA and stroke, including inter-relational pathophysiology. This review also highlights the importance of OSA treatment and its role in stroke outcomes. Knowledge of pathophysiology, the inter-relationship between these common disorders, and the impact of OSA therapy on outcomes affect the clinical management of patients with acute ischemic stroke. In addition, understanding the relationship between stroke outcomes and pre-existing OSA will allow clinicians to predict outcomes while treating acute stroke.
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Affiliation(s)
- Basma Mohamed
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Keerthi Yarlagadda
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Zachary Self
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Alexandra Simon
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Frank Rigueiro
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Maryam Sohooli
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Stephan Eisenschenk
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Sylvain Doré
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine, Gainesville, FL, 32610, USA.
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, 32610, USA.
- Departments of Neurology, Psychiatry, Pharmaceutics, and Neuroscience, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida College of Medicine, Gainesville, FL, 32610, USA.
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Sun B, Ma Q, Shen J, Meng Z, Xu J. Up-to-date advance in the relationship between OSA and stroke: a narrative review. Sleep Breath 2024; 28:53-60. [PMID: 37632670 DOI: 10.1007/s11325-023-02904-2] [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: 05/27/2023] [Revised: 07/26/2023] [Accepted: 08/11/2023] [Indexed: 08/28/2023]
Abstract
PURPOSE Obstructive sleep apnea (OSA) and stroke affect each other. In this review, we summarized the effect of OSA on the onset and recurrence of stroke, the prognosis, and the treatment of poststroke patients with OSA. METHODS Pubmed/MEDLINE were searched through May 2023 to explore the relationship between OSA and stroke. The relevant papers included OSA and stroke, OSA and recurrent stroke, and the prognosis and treatment of poststroke patients with OSA. RESULTS The results showed that OSA can promote the onset and recurrence of stroke and that OSA may adversely affect the prognosis of poststroke patients. The application of continuous positive airway pressure (CPAP) and other treatments may benefit poststroke patients with OSA, though the long term effects of treatment are not well documented. CONCLUSION Both the onset and recurrence of stroke closely correlated with OSA, but the specific mechanisms remain unclear. Further studies should be carried out to explore effective treatments in patients with stroke and OSA.
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Affiliation(s)
- Bo Sun
- Department of Respiratory and Critical Care Medicine, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, 6 Beijing Road West, Huaian, 223300, Jiangsu, China
| | - Qiyun Ma
- Department of Respiratory and Critical Care Medicine, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, 6 Beijing Road West, Huaian, 223300, Jiangsu, China
| | - Jiani Shen
- Department of Respiratory and Critical Care Medicine, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, 6 Beijing Road West, Huaian, 223300, Jiangsu, China
| | - Zili Meng
- Department of Respiratory and Critical Care Medicine, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, 6 Beijing Road West, Huaian, 223300, Jiangsu, China
| | - Jing Xu
- Department of Respiratory and Critical Care Medicine, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, 6 Beijing Road West, Huaian, 223300, Jiangsu, China.
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Tayade K, Vibha D, Singh RK, Pandit AK, Ramanujam B, Das A, Elavarasi A, Agarwal A, Srivastava AK, Tripathi M. Prevalence and determinants of post-stroke sleep disorders: a cross-sectional hospital-based study. Sleep Breath 2023; 27:2429-2433. [PMID: 37183196 DOI: 10.1007/s11325-023-02850-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 05/02/2023] [Accepted: 05/10/2023] [Indexed: 05/16/2023]
Abstract
INTRODUCTION Post-stroke sleep disorders (PSSD) are an important part of post-stroke disability. PSSD is neglected as a part of stroke rehabilitation. We aimed to study the prevalence and determinants of PSSD in a hospital based, single center setting. METHODS In a cross-sectional study, adult patients (≥ 18 years) with stroke (one month to one year after the onset), were enrolled in the study. Demographic, clinical, radiological, and motor and functional disabilities were assessed. Sleep quality was assessed with Pittsburg Sleep Quality Index (PSQI) and STOP BANG questionnaire (for obstructive sleep apnea [OSA]). Patients with poor sleep quality (PSQI > 5) were analyzed for risk factors. RESULTS A total of 103 patients were recruited in the study period (January 2021 to June 2022). The self-reported prevalence of PSSD was 16% which increased to 72% when the PSQI was administered. High risk of OSA was present in 33%. In bivariate analysis, factors associated with PSQI > 5 were involvement of ≥ 2 lobes, lower body mass index (BMI), worse modified Rankin Scale (mRS), Hamilton Depression Rating Scale (HAM-D), Hamilton Anxiety Rating Scale (HAM-A) and Stroke Specific Quality of Life (SSQoL). In multivariate analysis, only depression was associated with PSQI > 5 (OR: 1.3 (1.0; 1.7); p-value = 0.03). CONCLUSION PSSD had a prevalence of 72%. In multivariate analysis, the factor associated with PSQI > 5 was worse HAM-D score.
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Affiliation(s)
- Kamalesh Tayade
- Neurosciences Center, Department of Neurology, All India Institute of Medical Sciences, Room number 707, 7th Floor, New Delhi, India
| | - Deepti Vibha
- Neurosciences Center, Department of Neurology, All India Institute of Medical Sciences, Room number 707, 7th Floor, New Delhi, India.
| | - Rajesh Kumar Singh
- Neurosciences Center, Department of Neurology, All India Institute of Medical Sciences, Room number 707, 7th Floor, New Delhi, India
| | - Awadh Kishor Pandit
- Neurosciences Center, Department of Neurology, All India Institute of Medical Sciences, Room number 707, 7th Floor, New Delhi, India
| | - Bhargavi Ramanujam
- Neurosciences Center, Department of Neurology, All India Institute of Medical Sciences, Room number 707, 7th Floor, New Delhi, India
| | - Animesh Das
- Neurosciences Center, Department of Neurology, All India Institute of Medical Sciences, Room number 707, 7th Floor, New Delhi, India
| | - Arunmozhimaran Elavarasi
- Neurosciences Center, Department of Neurology, All India Institute of Medical Sciences, Room number 707, 7th Floor, New Delhi, India
| | - Ayush Agarwal
- Neurosciences Center, Department of Neurology, All India Institute of Medical Sciences, Room number 707, 7th Floor, New Delhi, India
| | - Achal Kumar Srivastava
- Neurosciences Center, Department of Neurology, All India Institute of Medical Sciences, Room number 707, 7th Floor, New Delhi, India
| | - Manjari Tripathi
- Neurosciences Center, Department of Neurology, All India Institute of Medical Sciences, Room number 707, 7th Floor, New Delhi, India
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Baillieul S, Denis C, Barateau L, Arquizan C, Detante O, Pépin JL, Dauvilliers Y, Tamisier R. The multifaceted aspects of sleep and sleep-wake disorders following stroke. Rev Neurol (Paris) 2023; 179:782-792. [PMID: 37612191 DOI: 10.1016/j.neurol.2023.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 08/25/2023]
Abstract
Sleep-wake disorders (SWD) are acknowledged risk factors for both ischemic stroke and poor cardiovascular and functional outcome after stroke. SWD are frequent following stroke, with sleep apnea (SA) being the most frequent SWD affecting more than half of stroke survivors. While sleep disturbances and SWD are frequently reported in the acute phase, they may persist in the chronic phase after an ischemic stroke. Despite the frequency and risk associated with SWD following stroke, screening for SWD remains rare in the clinical setting, due to challenges in the assessment of post-stroke SWD, uncertainty regarding the optimal timing for their diagnosis, and a lack of clear treatment guidelines (i.e., when to treat and the optimal treatment strategy). However, little evidence support the feasibility of SWD treatment even in the acute phase of stroke and its favorable effect on long-term cardiovascular and functional outcomes. Thus, sleep health recommendations and SWD treatment should be systematically embedded in secondary stroke prevention strategy. We therefore propose that the management of SWD associated with stroke should rely on a multidisciplinary approach, with an integrated diagnostic, treatment, and follow-up strategy. The challenges in the field are to improve post-stroke SWD diagnosis, prognosis and treatment, through a better appraisal of their pathophysiology and temporal evolution.
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Affiliation(s)
- S Baillieul
- Université Grenoble Alpes, Inserm, U1300, CHU Grenoble Alpes, Service Universitaire de Pneumologie Physiologie, 38000 Grenoble, France.
| | - C Denis
- National Reference Centre for Orphan Diseases Narcolepsy Rare Hypersomnias, Sleep Disorders Unit, Department of Neurology, CHU de Montpellier, University of Montpellier, Montpellier, France
| | - L Barateau
- National Reference Centre for Orphan Diseases Narcolepsy Rare Hypersomnias, Sleep Disorders Unit, Department of Neurology, CHU de Montpellier, University of Montpellier, Montpellier, France; Institute for Neurosciences of Montpellier (INM), University of Montpellier, Inserm, Montpellier, France
| | - C Arquizan
- Department of Neurology, Hôpital Gui-de-Chauliac, Montpellier, France; Inserm U1266, Paris, France
| | - O Detante
- Neurology Department, Grenoble Alpes University Hospital, Grenoble, France
| | - J-L Pépin
- Université Grenoble Alpes, Inserm, U1300, CHU Grenoble Alpes, Service Universitaire de Pneumologie Physiologie, 38000 Grenoble, France
| | - Y Dauvilliers
- National Reference Centre for Orphan Diseases Narcolepsy Rare Hypersomnias, Sleep Disorders Unit, Department of Neurology, CHU de Montpellier, University of Montpellier, Montpellier, France; Institute for Neurosciences of Montpellier (INM), University of Montpellier, Inserm, Montpellier, France
| | - R Tamisier
- Université Grenoble Alpes, Inserm, U1300, CHU Grenoble Alpes, Service Universitaire de Pneumologie Physiologie, 38000 Grenoble, France
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Fu S, Peng X, Li Y, Yang L, Yu H. Effectiveness and feasibility of continuous positive airway pressure in patients with stroke and sleep apnea: a meta-analysis of randomized trials. J Clin Sleep Med 2023; 19:1685-1696. [PMID: 37664950 PMCID: PMC10476038 DOI: 10.5664/jcsm.10680] [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: 09/07/2022] [Revised: 06/01/2023] [Accepted: 06/01/2023] [Indexed: 09/05/2023]
Abstract
STUDY OBJECTIVES This meta-analysis aimed to investigate the feasibility and effectiveness of continuous positive airway pressure (CPAP) treatment in stroke patients with sleep apnea. METHODS PubMed, EMBASE, and the Cochrane Library were searched from inception until July 28, 2022, for randomized controlled trials comparing the use of CPAP and usual treatment in patients with stroke or transient ischemic attack and sleep apnea. The primary outcome measures were the feasibility of CPAP therapy, neurological function, and functional status. RESULTS After screening 5,747 studies, 14 studies with 1,065 patients were included in this meta-analysis. Overall, 8 of the 14 studies recorded CPAP use, and the mean CPAP use was 4.47 hours per night (95% confidence interval [CI]: 3.85-5.09). The risk ratio of discontinuing CPAP was 1.50 (95% CI: 0.76-2.94; P = .24). Analysis of the neurofunctional scales showed that CPAP treatment improved neurological function (standardized mean difference: 0.28; 95% CI: 0.02-0.53), but there was substantial heterogeneity (I2 = 57%, P = .03) across the studies. CPAP treatment had no significant effect on functional status vs the control (standardized mean difference: 0.25; 95% CI: -0.01 to 0.51), but the studies also had substantial heterogeneity (I2 = 55%, P = .06). CONCLUSIONS CPAP treatment is feasible in patients with stroke and sleep apnea and may improve neurological outcomes in these patients. However, this finding should be interpreted with caution because of the substantial heterogeneity of current trials. CITATION Fu S, Peng X, Li Y, Yang L, Yu H. Effectiveness and feasibility of continuous positive airway pressure in patients with stroke and sleep apnea: a meta-analysis of randomized trials. J Clin Sleep Med. 2023;19(9):1685-1696.
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Affiliation(s)
- Shasha Fu
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaohua Peng
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yi Li
- Department of Rehabilitation Medicine, People’s Hospital of Chongqing Banan District, Chongqing, China
| | - Lining Yang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Heping Yu
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Šiarnik P, Jurík M, Valovičová K, Klobučníková K, Kollár B, Poddaný M, Rovňák M, Turčáni P, Sýkora M. Adherence to positive airway pressure therapy initiated in the early subacute phase of ischemic stroke: a PRESS study follow-up. Sleep Breath 2023; 27:1279-1286. [PMID: 36198999 PMCID: PMC9534463 DOI: 10.1007/s11325-022-02722-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 08/05/2022] [Accepted: 09/30/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Sleep-disordered breathing (SDB) is frequent in stroke patients and negatively affects stroke outcomes. Positive airway pressure (PAP) is the standard first-line treatment for patients with moderate-to-severe SDB. Despite a strong link between PAP adherence and therapeutic response, rates of post-stroke PAP adherence remain underexplored. Our study aimed to determine PAP adherence in patients undergoing comprehensive sleep apnea assessment and in-lab PAP titration in the early subacute phase of stroke. METHODS In-hospital screening pulse oximetry was performed in consecutive patients with imaging-confirmed acute ischemic stroke. Subjects with desaturation index ≥ 15.3/h were selected as PAP candidates, and polysomnography was recommended. In a sleep laboratory setting, subjects underwent a diagnostic night followed by a titration night, and PAP therapy was initiated in subjects with apnea-hypopnea index ≥ 15/h. Adherence to PAP therapy was assessed at a 6-month follow-up visit. RESULTS Of 225 consecutive patients with acute ischemic stroke, 116 were PAP candidates and 52 were able to undergo polysomnography. PAP therapy was initiated in 35 subjects. At a 6-month follow-up visit, out of 34 stroke survivors, PAP adherence (PAP use of > 4 h per night) was present in 47%. Except for the significantly lower minimal nocturnal O2 saturation determined from the polysomnography (74.6 ± 11.7% vs. 81.8 ± 5.2%, p = 0.025), no other significant difference in characteristics of the groups with PAP adherence and PAP non-adherence was found. CONCLUSIONS Less than half of the stroke subjects remained adherent to PAP therapy at 6 months post-PAP initiation. Special attention to support adaptation and adherence to PAP treatment is needed in this group of patients.
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Affiliation(s)
- Pavel Šiarnik
- 1st Department of Neurology, Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovakia
| | - Matúš Jurík
- 1st Department of Neurology, Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovakia
| | - Katarína Valovičová
- 1st Department of Neurology, Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovakia
| | - Katarína Klobučníková
- 1st Department of Neurology, Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovakia
| | - Branislav Kollár
- 1st Department of Neurology, Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovakia
| | - Michal Poddaný
- Department of Neurology, General Hospital, Liptovsky Mikulas, Slovakia
| | - Marek Rovňák
- Jessenius Faculty of Medicine, Comenius University in Bratislava, University Hospital in Martin, Martin, Slovakia
| | - Peter Turčáni
- 1st Department of Neurology, Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovakia
| | - Marek Sýkora
- 1st Department of Neurology, Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovakia
- Department of Neurology, St. John’s Hospital, Medical Faculty, Sigmund Freud University Vienna, Vienna, Austria
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10
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Chang JL, Goldberg AN, Alt JA, Alzoubaidi M, Ashbrook L, Auckley D, Ayappa I, Bakhtiar H, Barrera JE, Bartley BL, Billings ME, Boon MS, Bosschieter P, Braverman I, Brodie K, Cabrera-Muffly C, Caesar R, Cahali MB, Cai Y, Cao M, Capasso R, Caples SM, Chahine LM, Chang CP, Chang KW, Chaudhary N, Cheong CSJ, Chowdhuri S, Cistulli PA, Claman D, Collen J, Coughlin KC, Creamer J, Davis EM, Dupuy-McCauley KL, Durr ML, Dutt M, Ali ME, Elkassabany NM, Epstein LJ, Fiala JA, Freedman N, Gill K, Boyd Gillespie M, Golisch L, Gooneratne N, Gottlieb DJ, Green KK, Gulati A, Gurubhagavatula I, Hayward N, Hoff PT, Hoffmann OM, Holfinger SJ, Hsia J, Huntley C, Huoh KC, Huyett P, Inala S, Ishman SL, Jella TK, Jobanputra AM, Johnson AP, Junna MR, Kado JT, Kaffenberger TM, Kapur VK, Kezirian EJ, Khan M, Kirsch DB, Kominsky A, Kryger M, Krystal AD, Kushida CA, Kuzniar TJ, Lam DJ, Lettieri CJ, Lim DC, Lin HC, Liu SY, MacKay SG, Magalang UJ, Malhotra A, Mansukhani MP, Maurer JT, May AM, Mitchell RB, Mokhlesi B, Mullins AE, Nada EM, Naik S, Nokes B, Olson MD, Pack AI, Pang EB, Pang KP, Patil SP, Van de Perck E, Piccirillo JF, Pien GW, Piper AJ, Plawecki A, Quigg M, Ravesloot MJ, Redline S, Rotenberg BW, Ryden A, Sarmiento KF, Sbeih F, Schell AE, Schmickl CN, Schotland HM, Schwab RJ, Seo J, Shah N, Shelgikar AV, Shochat I, Soose RJ, Steele TO, Stephens E, Stepnowsky C, Strohl KP, Sutherland K, Suurna MV, Thaler E, Thapa S, Vanderveken OM, de Vries N, Weaver EM, Weir ID, Wolfe LF, Tucker Woodson B, Won CH, Xu J, Yalamanchi P, Yaremchuk K, Yeghiazarians Y, Yu JL, Zeidler M, Rosen IM. International Consensus Statement on Obstructive Sleep Apnea. Int Forum Allergy Rhinol 2023; 13:1061-1482. [PMID: 36068685 PMCID: PMC10359192 DOI: 10.1002/alr.23079] [Citation(s) in RCA: 62] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA). METHODS Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus. RESULTS The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated. CONCLUSION This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.
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Affiliation(s)
- Jolie L. Chang
- University of California, San Francisco, California, USA
| | | | | | | | - Liza Ashbrook
- University of California, San Francisco, California, USA
| | | | - Indu Ayappa
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | - Maurits S. Boon
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Pien Bosschieter
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | - Itzhak Braverman
- Hillel Yaffe Medical Center, Hadera Technion, Faculty of Medicine, Hadera, Israel
| | - Kara Brodie
- University of California, San Francisco, California, USA
| | | | - Ray Caesar
- Stone Oak Orthodontics, San Antonio, Texas, USA
| | | | - Yi Cai
- University of California, San Francisco, California, USA
| | | | | | | | | | | | | | | | | | - Susmita Chowdhuri
- Wayne State University and John D. Dingell VA Medical Center, Detroit, Michigan, USA
| | - Peter A. Cistulli
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - David Claman
- University of California, San Francisco, California, USA
| | - Jacob Collen
- Uniformed Services University, Bethesda, Maryland, USA
| | | | | | - Eric M. Davis
- University of Virginia, Charlottesville, Virginia, USA
| | | | | | - Mohan Dutt
- University of Michigan, Ann Arbor, Michigan, USA
| | - Mazen El Ali
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | - Kirat Gill
- Stanford University, Palo Alto, California, USA
| | | | - Lea Golisch
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | | | | | - Arushi Gulati
- University of California, San Francisco, California, USA
| | | | | | - Paul T. Hoff
- University of Michigan, Ann Arbor, Michigan, USA
| | - Oliver M.G. Hoffmann
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | - Jennifer Hsia
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Colin Huntley
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | | | - Sanjana Inala
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | | | | | | | | | | | - Meena Khan
- Ohio State University, Columbus, Ohio, USA
| | | | - Alan Kominsky
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | - Meir Kryger
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Derek J. Lam
- Oregon Health and Science University, Portland, Oregon, USA
| | | | | | | | | | | | | | - Atul Malhotra
- University of California, San Diego, California, USA
| | | | - Joachim T. Maurer
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - Anna M. May
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Ron B. Mitchell
- University of Texas, Southwestern and Children’s Medical Center Dallas, Texas, USA
| | | | | | | | | | - Brandon Nokes
- University of California, San Diego, California, USA
| | | | - Allan I. Pack
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | | | | | | | | | | | | - Mark Quigg
- University of Virginia, Charlottesville, Virginia, USA
| | | | - Susan Redline
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Armand Ryden
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | | | - Firas Sbeih
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | | | | | | | | | - Jiyeon Seo
- University of California, Los Angeles, California, USA
| | - Neomi Shah
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | - Ryan J. Soose
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Erika Stephens
- University of California, San Francisco, California, USA
| | | | | | | | | | - Erica Thaler
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sritika Thapa
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Nico de Vries
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | | | - Ian D. Weir
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Josie Xu
- University of Toronto, Ontario, Canada
| | | | | | | | | | | | - Ilene M. Rosen
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
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11
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Hoang-Anh T, Duong-Minh Q, Nguyen-Thi-Y N, Duong-Quy S. Study of the obstructive sleep apnea syndrome in cerebral infarction patients. Front Neurol 2023; 14:1132014. [PMID: 37416312 PMCID: PMC10321128 DOI: 10.3389/fneur.2023.1132014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 05/02/2023] [Indexed: 07/08/2023] Open
Abstract
Introduction Obstructive Sleep Apnea Syndrome (OSAS) is the most common respiratory disorder during sleep. Many studies have shown an association between obstructive sleep apnea syndrome and stroke, and OSAS has not been adequately considered in Vietnam compared to the actual clinical dangers. This study aims to assess the prevalence and general characteristics of obstructive sleep apnea syndrome in patients with cerebral infarction and investigate the relationship between obstructive sleep apnea syndrome and the severity of cerebral infarction. Methods Descriptive cross-sectional study. We identified 56 participants from August 2018 to July 2019. Subacute infarcts were identified by neuroradiologists. For each participant, vascular risk factors, medications, clinical symptoms, and neurological examination were abstracted from the medical record. Patients were taken for history and clinical examination. The patients were divided into two groups according to their AHI (Apnea-Hypopnea Index) (<5 and ≥5). Results A total of 56 patients were registered for the study. The mean age is 67.70 ± 11.07. The proportion of men is 53.6%. AHI has a positive correlation with neck circumference (r = 0.4), BMI (r = 0.38), the Epworth Sleepiness Scale (r = 0.61), LDL cholesterol (r = 0.38), the Modified Rankin Scale (r = 0.49), NIHSS (National Institutes of Health Stroke Scale) (r = 0.53), and an inverse correlation with SpO2 (r = 0.61). Conclusion Obstructive sleep apnea Syndrome is a factor in the prognosis of cerebral infarction as well as cardiovascular diseases such as hypertension. Thus, understanding the risk of stroke in people with sleep apnea is necessary and working with a doctor to diagnose and treat sleep apnea is important.
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Affiliation(s)
- Tien Hoang-Anh
- Cardiology Department of University of Medicine and Pharmacy, Hue University, Hue, Vietnam
| | - Quy Duong-Minh
- Cardiology Department of University of Medicine and Pharmacy, Hue University, Hue, Vietnam
| | - Nhi Nguyen-Thi-Y
- Cardiology Department of University of Medicine and Pharmacy, Hue University, Hue, Vietnam
| | - Sy Duong-Quy
- Sleep Lab Center, Lam Dong Medical College and Bio-Medical Research Center, Dalat, Vietnam
- Immuno-Allergology Division, Hershey Medical Center, Penn State Medical College, Hershey, PA, United States
- Department of Outpatient Expert Consultation, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
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12
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Hale E, Gottlieb E, Usseglio J, Shechter A. Post-stroke sleep disturbance and recurrent cardiovascular and cerebrovascular events: A systematic review and meta-analysis. Sleep Med 2023; 104:29-41. [PMID: 36889030 PMCID: PMC10098455 DOI: 10.1016/j.sleep.2023.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 02/10/2023] [Accepted: 02/18/2023] [Indexed: 02/22/2023]
Abstract
Despite improvements in survival rates, risk of recurrent events following stroke remains high. Identifying intervention targets to reduce secondary cardiovascular risk in stroke survivors is a priority. The relationship between sleep and stroke is complex: sleep disturbances are likely both a contributor to, and consequence of, stroke. The current aim was to examine the association between sleep disturbance and recurrent major acute coronary events or all-cause mortality in the post-stroke population. Thirty-two studies were identified, including 22 observational studies and 10 randomized clinical trials (RCTs). Identified studies included the following as predictors of post-stroke recurrent events: obstructive sleep apnea (OSA, n = 15 studies), treatment of OSA with positive airway pressure (PAP, n = 13 studies), sleep quality and/or insomnia (n = 3 studies), sleep duration (n = 1 study), polysomnographic sleep/sleep architecture metrics (n = 1 study), and restless legs syndrome (n = 1 study). A positive relationship of OSA and/or OSA severity with recurrent events/mortality was seen. Findings on PAP treatment for OSA were mixed. Positive findings indicating a benefit of PAP for post-stroke risk came largely from observational studies (pooled RR [95% CI] for association between PAP and recurrent cardiovascular event: 0.37 [0.17-0.79], I2 = 0%). Negative findings came largely from RCTs (RR [95% CI] for association between PAP and recurrent cardiovascular event + death: 0.70 [0.43-1.13], I2 = 30%). From the limited number of studies conducted to date, insomnia symptoms/poor sleep quality and long sleep duration were associated with increased risk. Sleep, a modifiable behavior, may be a secondary prevention target to reduce the risk of recurrent event and death following stroke. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42021266558.
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Affiliation(s)
- Evan Hale
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Elie Gottlieb
- The Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia; SleepScore Labs, Carslbad, CA, USA
| | - John Usseglio
- Center for Behavioral Cardiovascular Health, Columbia University Irving Medical Center, New York, NY, USA; Augustus C. Long Health Sciences Library, Columbia University Irving Medical Center, New York, NY, USA
| | - Ari Shechter
- Center for Behavioral Cardiovascular Health, Columbia University Irving Medical Center, New York, NY, USA; Center of Excellence for Sleep & Circadian Research, Columbia University Irving Medical Center, New York, NY, USA.
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13
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Toh ZA, Cheng LJ, Wu XV, De Silva DA, Oh HX, Ng SX, He HG, Pikkarainen M. Positive airway pressure therapy for post-stroke sleep disordered breathing: a systematic review, meta-analysis and meta-regression. Eur Respir Rev 2023; 32:32/167/220169. [PMID: 36889784 PMCID: PMC10032615 DOI: 10.1183/16000617.0169-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 10/24/2022] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Sleep disordered breathing (SDB) is an under-recognised independent risk factor and a potential consequence of stroke. We systematically reviewed and meta-analysed the effectiveness of positive airway pressure (PAP) therapy in improving post-stroke outcomes. METHODS We searched CENTRAL, Embase, PubMed, CINAHL, PsycINFO, Scopus, ProQuest, Web of Science and CNKI (China National Knowledge Infrastructure) for randomised controlled trials comparing PAP therapy against a control or placebo group. We evaluated the pooled effects of PAP therapy on recurrent vascular events, neurological deficit, cognition, functional independence, daytime sleepiness and depression using random effects meta-analyses. RESULTS We identified 24 studies. Our meta-analyses showed that PAP therapy reduced recurrent vascular events (risk ratio 0.47, 95% CI 0.28-0.78), and showed significant beneficial effects on neurological deficit (Hedges' g= -0.79, 95% CI -1.19- -0.39), cognition (g=0.85, 95% CI 0.04-1.65), functional independence (g=0.45, 95% CI 0.01-0.88) and daytime sleepiness (g= -0.96, 95% CI -1.56- -0.37). However, there was insignificant reduction in depression (g= -0.56, 95% CI -2.15-1.02). No publication bias was detected. CONCLUSIONS Post-stroke patients with SDB benefited from PAP therapy. Prospective trials are needed to determine the ideal initiation period and the minimum effective therapeutic dose.
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Affiliation(s)
- Zheng An Toh
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Nursing, National University Hospital, Singapore
- National University Health System, Singapore
| | - Ling Jie Cheng
- National University Health System, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Xi Vivien Wu
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- National University Health System, Singapore
| | - Deidre Anne De Silva
- Department of Neurology, Singapore General Hospital Campus, National Neuroscience Institute, Singapore
| | - Hui Xian Oh
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Nursing, National University Hospital, Singapore
- National University Health System, Singapore
| | - Si Xian Ng
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Nursing, National University Hospital, Singapore
- National University Health System, Singapore
| | - Hong-Gu He
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- National University Health System, Singapore
| | - Minna Pikkarainen
- Department of Occupational Therapy, Prosthetics and Orthoptics, Faculty of Health Sciences and Department of Product Design, Faculty of Technology, Art and Design, Oslo Metropolitan University, Oslo, Norway
- Martti Ahtisaari Institute, University of Oulu, Oulu, Finland
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14
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Sleep-Disordered Breathing in Acute Stroke: A Single-Center, Prospective, Longitudinal Study. J Clin Med 2023; 12:jcm12030986. [PMID: 36769634 PMCID: PMC9917629 DOI: 10.3390/jcm12030986] [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: 12/30/2022] [Revised: 01/21/2023] [Accepted: 01/24/2023] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Sleep-disordered breathing (SDB) is common among acute stroke patients. We sought to investigate the prevalence, severity and type of SDB in consecutive acute stroke patients. Moreover, we aimed to identify independent predictors of SDB in the acute stroke setting and investigate potential associations between SDB and functional outcomes at three months. METHODS We prospectively studied consecutive acute stroke patients, who underwent overnight polysomnography within 72 h from symptom onset. Demographics, clinical and imaging characteristics were documented. Daytime sleepiness preceding the stroke, stroke severity on admission and functional outcome at three months were evaluated using the Epworth-Sleepiness Scale (ESS), National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS), respectively. SDB was documented using standard polysomnography criteria. RESULTS A total of 130 consecutive acute stroke patients were prospectively evaluated [110 with ischemic stroke and 20 with intracerebral hemorrhage, mean age 60.5 ± 10.9 years, 77% men, median NIHSS score on admission: 3 (IQR: 2-17)]. The rate of SDB detection on polysomnography recordings was 79% (95% CI: 71-86). Three variables were independently associated with the likelihood of SDB detection in multivariable analyses adjusting for potential confounders: age (OR per 10-year-increase: 2.318, 95% CI: 1.327-4.391, p = 0.005), male sex (OR: 7.901, 95% CI: 2.349-30.855, p = 0.001) and abnormal ESS-score (OR: 6.064, 95% CI: 1.560-32.283, p = 0.017). Among patients with SDB, congestive heart failure was independently associated with the likelihood of central apnea detection (OR: 18.295, 95% CI: 4.464-19.105, p < 0.001). Among all patients, increasing NIHSS score on admission (OR: 0.817, 95% CI: 0.737-0.891, p < 0.001) and Apnea-Hypopnea Index (OR: 0.979, 95% CI: 0.962-0.996, p = 0.020) emerged as independent predictors of excellent functional outcome at 3 months (mRS-scores 0-1). CONCLUSION The high prevalence and severity of SDB in acute stroke patients and its negative impact on functional outcome indicate the importance of polysomnography implementation in everyday clinical practice of acute stroke work-up and management.
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15
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Yang Y, Wu W, Huang H, Wu H, Huang J, Li L, Wang L. Effect of CPAP on cognitive function in stroke patients with obstructive sleep apnoea: a meta-analysis of randomised controlled trials. BMJ Open 2023; 13:e060166. [PMID: 36627155 PMCID: PMC9835870 DOI: 10.1136/bmjopen-2021-060166] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To investigate the effect of continuous positive airway pressure (CPAP) treatment on cognitive function in stroke patients with obstructive sleep apnoea (OSA) by exploring randomised controlled trials (RCTs). METHODS Published RCTs that assessed the therapeutic effects of CPAP on cognition in stroke patients with OSA, compared with controls or sham CPAP, were included. Electronic databases, including MEDLINE, Embase and Cochrane library, were searched in October 2020 and October 2021. Risk of bias was assessed using the Cochrane collaboration tools. A random effects or fixed effects model was used according to heterogeneity. The outcomes were global cognitive gain, improvement in cognitive domain and subjective sleepiness. RESULTS 7 RCTs, including 327 participants, comparing CPAP with control or sham CPAP treatment were included. 6 RCTs with 270 participants reported results related to global cognition, and CPAP treatment had no significant effects on global cognitive gain in stroke patients with OSA (standardised mean difference (SMD), 0.18; 95% CI, -0.07 to 0.42; p=0.153). A subgroup analysis showed that an early start to (<2 weeks post stroke) CPAP treatment after stroke significantly improved global cognition (SMD, 0.66; 95% CI, 0.18 to 1.14; p=0.007), which was not found in the case of a delayed start to CPAP treatment. However, CPAP did not significantly help with memory, language, attention or executive function. Moreover, CPAP therapy significantly alleviated subjective sleepiness (SMD, -0.73; 95% CI, -1.15 to -0.32; p≤0.001). CONCLUSIONS Early initiation of CPAP treatment might contribute to improvement in global cognition in stroke patients with OSA. This study had the following limitations: the sample size in each included study was relatively small; the scales related to cognitive assessment or subjective sleepiness were inconsistent; and the methodological quality was not high. Future trials should focus on including a greater number of stroke patients with OSA undergoing CPAP treatment. PROSPERO REGISTRATION NUMBER CRD42020214709.
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Affiliation(s)
- Yingxia Yang
- Department of Neurology, Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
| | - Weiqi Wu
- Department of Neurology, Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
| | - Honghong Huang
- Department of Neurology, Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
| | - Haining Wu
- Department of Neurology, Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
| | - Junying Huang
- Department of Neurology, Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
| | - Liya Li
- Department of Ultrasound, Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
| | - Lingxing Wang
- Department of Neurology, Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
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16
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Malhamé I, Bublitz MH, Wilson D, Sanapo L, Rochin E, Bourjeily G. Sleep disordered breathing and the risk of severe maternal morbidity in women with preeclampsia: A population-based study. Pregnancy Hypertens 2022; 30:215-220. [PMID: 36343510 PMCID: PMC9712248 DOI: 10.1016/j.preghy.2022.10.013] [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: 02/10/2022] [Revised: 10/13/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Obstructive sleep apnea (OSA) may exacerbate the widespread endothelial dysfunction seen in preeclampsia, potentially worsening clinical outcomes. We aimed to assess whether OSA is associated with an increased risk of severe maternal morbidity, cardiovascular morbidity, and healthcare utilization among women with preeclampsia. STUDY DESIGN We performed a retrospective cohort study utilizing data from the National Perinatal Information Center (2010-2014) in the United States.The cohort comprised women with preeclampsia. We estimated the association between OSA and the outcomes using logistic regression analyses and determined odds ratio adjusted for demographic factors and comorbidities (ORadj) and associated 95% confidence intervals (CI). MAIN OUTCOME MEASURES The primary outcome was a composite of mortality and severe maternal morbidity comprising intensive care unit (ICU) admission, acute renal failure, pulmonary edema, pulmonary embolism, congestive heart failure, cardiomyopathy, and stroke. Secondary outcomes comprised the subset of cardiovascular events, as well as increased healthcare utilization (including Cesarean delivery, preterm birth, ICU admission, and prolonged length of hospital stay). RESULTS In total, 71,159 women had preeclampsia, including 270 (0.4 %) with OSA. Women with preeclampsia and OSA were more likely to experience severe maternal morbidity than women without OSA (ORadj 2.65, 95 % CI [1.94-3.61]). Moreover, women with concomitant OSA had more severe cardiovascular morbidity than women without OSA (ORadj 5.05, 95 % CI [2.28-11.17]). Accordingly, OSA was associated with increased healthcare utilization in women with preeclampsia (ORadj. 2.26, 95 % CI [1.45-3.52]). CONCLUSION In women with preeclampsia, OSA increases the risk for severe maternal morbidity, cardiovascular morbidity, and healthcare utilization.
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Affiliation(s)
- Isabelle Malhamé
- Department of Medicine, McGill University Health Centre, Montreal, Canada; Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Margaret H Bublitz
- Psychiatry and Human Behavior and Medicine, The Miriam Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Danielle Wilson
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Laura Sanapo
- Psychiatry and Human Behavior and Medicine, The Miriam Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Elizabeth Rochin
- National Perinatal Information Center, Providence, RI, United States
| | - Ghada Bourjeily
- Psychiatry and Human Behavior and Medicine, The Miriam Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States.
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17
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Boulos MI, Chi L, Chernyshev OY. The mobile sleep medicine model in neurologic practice: Rationale and application. Front Neurol 2022; 13:1032463. [PMID: 36388176 PMCID: PMC9650181 DOI: 10.3389/fneur.2022.1032463] [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: 08/30/2022] [Accepted: 09/22/2022] [Indexed: 11/29/2022] Open
Abstract
Background Undiagnosed obstructive sleep apnea (OSA) is prevalent in neurological practice and significantly contributes to morbidity and mortality. OSA is prevalent in US adults and causes poor quality sleep and significant neurocognitive, cardiovascular, and cerebrovascular impairments. Timely treatment of OSA reduces cardio-cerebrovascular risks and improves quality of life. However, most of the US population has limited systematic access to sleep medicine care despite its clinical significance. Focus We discuss the importance of systematic screening, testing, and best-practice management of OSA and hypoventilation/hypoxemia syndromes (HHS) in patients with stroke, neurocognitive impairment, and neuromuscular conditions. This review aims to introduce and describe a novel integrated Mobile Sleep Medicine (iMSM) care model and provide the rationale for using an iMSM in general neurological practice to assist with systematic screening, testing and best-practice management of OSA, HHS, and potentially other sleep conditions. Key points The iMSM is an innovative, patient-centered, clinical outcome-based program that uses a Mobile Sleep Medicine Unit—a “sleep lab on wheels”—designed to improve access to OSA management and sleep care at all levels of health care system. The protocol for the iMSM care model includes three levels of operations to provide effective and efficient OSA screening, timely testing/treatment plans, and coordination of further sleep medicine care follow-up. The iMSM care model prioritizes effective, efficient, and patient-centered sleep medicine care; therefore, all parties and segments of care that receive and provide clinical sleep medicine services may benefit from adopting this innovative approach.
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Affiliation(s)
- Mark I. Boulos
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Sleep Laboratory, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Luqi Chi
- Washington University School of Medicine, St. Louis, MO, United States
| | - Oleg Y. Chernyshev
- Sleep Medicine Division, Department of Neurology, Louisiana State University Health Sciences Center, Shreveport, LA, United States
- Ochsner LSU Health Sleep Medicine Center, Shreveport, LA, United States
- *Correspondence: Oleg Y. Chernyshev
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18
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Li YE, Ren J. Association between obstructive sleep apnea and cardiovascular diseases. Acta Biochim Biophys Sin (Shanghai) 2022; 54:882-892. [PMID: 35838200 PMCID: PMC9828315 DOI: 10.3724/abbs.2022084] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Obstructive sleep apnea (OSA) is a common respiratory disorder characterized by partial obstruction of upper respiratory tract and repetitive cessation of breathing during sleep. The etiology behind OSA is associated with the occurrence of intermittent hypoxemia, recurrent arousals and intrathoracic pressure swings. These contributing factors may turn on various signaling mechanisms including elevated sympathetic tone, oxidative stress, inflammation, endothelial dysfunction, cardiovascular variability, abnormal coagulation and metabolic defect ( e.g., insulin resistance, leptin resistance and altered hepatic metabolism). Given its close tie with major cardiovascular risk factors, OSA is commonly linked to the pathogenesis of a wide array of cardiovascular diseases (CVDs) including hypertension, heart failure, arrhythmias, coronary artery disease, stroke, cerebrovascular disease and pulmonary hypertension (PH). The current standard treatment for OSA using adequate nasal continuous positive airway pressure (CPAP) confers a significant reduction in cardiovascular morbidity. Nonetheless, despite the availability of effective therapy, patients with CVDs are still deemed highly vulnerable to OSA and related adverse clinical outcomes. A better understanding of the etiology of OSA along with early diagnosis should be essential for this undertreated disorder in the clinical setting.
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Affiliation(s)
- Yiran E. Li
- Department of CardiologyZhongshan HospitalFudan University; Shanghai Institute of Cardiovascular DiseasesShanghai200032China
| | - Jun Ren
- Department of CardiologyZhongshan HospitalFudan University; Shanghai Institute of Cardiovascular DiseasesShanghai200032China,Department of Laboratory Medicine and PathologyUniversity of WashingtonSeattleWA98195USA,Correspondence address. Tel: +86-21-64041990; E-mail:
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19
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Abstract
SUMMARY Ischemic strokes most often occur between 6 am and 12 am after awakening from sleep but up to 30% occur during sleep. Wake-up strokes (WUS) are new focal neurological deficit(s) persisting for ≥ 24 hours attributable to an ischemic event present on patient awakening. Obstructive sleep apnea (OSA) is a major risk factor for WUS because it compounds the instability of the morning environment and increases the likelihood of cardiovascular events, including hypertension, atrial fibrillation, right-to-left shunts, and stroke. Circadian-driven alterations in structural, homeostatic, and serological factors also predispose to WUS. Also, WUS patients are often not considered candidates for time-dependent intravenous thrombolysis therapy because of an uncertain onset time. However, using the tissue clock (positive diffusion weighted imaging-negative fluid-attenuated inversion recovery mismatch) dates the WUS as 3 to 4.5 hours old and permits consideration for intravenous thrombolysis and if needed mechanical thrombectomy. Given the high prevalence of moderate/severe OSA in stroke patients and its impact on stroke outcomes, screening with overnight pulse oximetry and home sleep apnea test is needed. Treating OSA poststroke remains challenging. Polysomnographic changes in sleep architecture following acute/subacute stroke may also impact upon stroke outcome.
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Affiliation(s)
- Atif Zafar
- Department of Neurology, University of Toronto, Toronto, ON, Canada
| | - Parth Dhruv
- Department of Neurology, Kaiser Permanente, Santa Clara, California, U.S.A
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20
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Gleeson M, McNicholas WT. Bidirectional relationships of comorbidity with obstructive sleep apnoea. Eur Respir Rev 2022; 31:31/164/210256. [PMID: 35508332 PMCID: PMC9488957 DOI: 10.1183/16000617.0256-2021] [Citation(s) in RCA: 58] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 02/07/2022] [Indexed: 11/26/2022] Open
Abstract
Obstructive sleep apnoea (OSA) is frequently associated with comorbidities that include metabolic, cardiovascular, renal, pulmonary and neuropsychiatric. There is considerable evidence that OSA is an independent risk factor for many of these comorbidities but, more recently, there is evidence that some of these comorbidities may predispose to the development of OSA. Thus, there is growing evidence of a bidirectional relationship between OSA and comorbidity, especially for heart failure, metabolic syndrome and stroke. Potential mechanisms of bidirectional relationships differ in individual comorbidities with fluid retention and redistribution being especially important in heart failure and end-stage renal disease, whereas neural mechanisms may be more important in diabetes mellitus and stroke. The evidence for other comorbidities, such as hypertension and atrial fibrillation, support these being more a consequence of OSA with limited evidence to support a bidirectional relationship. The present review explores the evidence for such bidirectional relationships with a particular perspective on comorbidities that may predispose to OSA. The impact of therapy in bidirectional relationships is also reviewed, which highlights the clinical importance of accurate diagnosis. This aspect is especially true of COPD, where the identification of co-existing OSA has important implications for optimum therapy. Obstructive sleep apnoea (OSA) is an independent risk factor for comorbidity, especially cardiometabolic. However, some comorbidities may be risk factors for OSA, supporting a bidirectional relationship that may have important implications for treatment.https://bit.ly/3BbJy6V
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Affiliation(s)
- Margaret Gleeson
- School of Medicine, University College Dublin, and Dept of Respiratory and Sleep Medicine, St. Vincent's Hospital Group, Dublin, Ireland
| | - Walter T McNicholas
- School of Medicine, University College Dublin, and Dept of Respiratory and Sleep Medicine, St. Vincent's Hospital Group, Dublin, Ireland
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21
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Abstract
OBJECTIVE Obstructive sleep apnoea (OSA) is a common cause of secondary hypertension. This network meta-analysis (NMA) assessed the effect of different OSA treatments on lowering blood pressure. METHODS PubMed, EMBASE, Web of Science, and Cochrane Library databases were searched for relevant randomized controlled trials. The search strategies included the concepts of OSA, blood pressure, hypertension, and blood pressure-reducing treatments without language or data restriction (from inception to 1 June 2021). The outcomes included office SBP, office DBP, daytime SBP (dSBP) and DBP (dDBP), and night-time SBP (nSBP) and DBP (nDBP). A Bayesian network meta-analysis was performed, and mean differences with 95% credibility intervals were calculated. RESULTS We reviewed 49 randomized controlled trials involving 4893 patients and the following interventions: continuous positive-airway pressure (CPAP), mandibular advancement devices, nocturnal supplemental oxygen, surgery, β-blocker, angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs), renal sympathetic denervation (RDN), mineralocorticoid receptor antagonists (MRAs), calcium channel blockers. MRAs were significantly associated with blood pressure reduction followed by ACEI/ARB. RDN could reduce office SBP, office DBP, 24-h SBP, 24-h DBP, dSBP, and dDBP. CPAP also demonstrated modest blood pressure lowering. CONCLUSION MRAs and ACEIs/ARBs can reduce blood pressure effectively in patients with OSA. RDN is a novel hypertension treatment that lowered blood pressure in such patients. CPAP was associated with mild but stable blood pressure reduction, and it might be helpful as an adjunctive therapy in OSA patients with hypertension. REVIEW REGISTRATION This systematic review and meta-analysis was registered in PROSPERO: CRD42021240891.
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22
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Barnett HM, Davis AP, Khot SP. Stroke and breathing. HANDBOOK OF CLINICAL NEUROLOGY 2022; 189:201-222. [PMID: 36031305 DOI: 10.1016/b978-0-323-91532-8.00016-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Stroke remains a leading cause of neurologic disability with wide ranging effects, including a variety of respiratory abnormalities. Stroke may influence the central control of the respiratory drive and breathing pattern, airway protection and maintenance, and the respiratory mechanics of inspiration and expiration. In the acute phase of stroke, the central control of breathing is affected by changes in consciousness, cerebral edema, and direct damage to brainstem respiratory centers, resulting in abnormalities in respiratory pattern and loss of airway protection. Common acute complications related to respiratory dysfunction include dysphagia, aspiration, and pneumonia. Respiratory control centers are located in the brainstem, and brainstem stroke causes specific patterns of respiratory dysfunction. Depending on the exact location and extent of stroke, respiratory failure may occur. While major respiratory abnormalities often improve over time, sleep-disordered breathing remains common in the subacute and chronic phases and worsens outcomes. Respiratory mechanics are impaired in hemiplegic or hemiparetic stroke, contributing to worse cardiopulmonary health in stroke survivors. Interventions to address the respiratory complications are under researched, and further investigation in this area is critical to improving outcomes among stroke survivors.
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Affiliation(s)
- Heather M Barnett
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, United States
| | - Arielle P Davis
- Department of Neurology, University of Washington, Seattle, WA, United States
| | - Sandeep P Khot
- Department of Neurology, University of Washington, Seattle, WA, United States.
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23
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Baillieul S, Dekkers M, Brill AK, Schmidt MH, Detante O, Pépin JL, Tamisier R, Bassetti CLA. Sleep apnoea and ischaemic stroke: current knowledge and future directions. Lancet Neurol 2021; 21:78-88. [PMID: 34942140 DOI: 10.1016/s1474-4422(21)00321-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/31/2021] [Accepted: 09/07/2021] [Indexed: 12/11/2022]
Abstract
Sleep apnoea, one of the most common chronic diseases, is a risk factor for ischaemic stroke, stroke recurrence, and poor functional recovery after stroke. More than half of stroke survivors present with sleep apnoea during the acute phase after stroke, with obstructive sleep apnoea being the most common subtype. Following a stroke, sleep apnoea frequency and severity might decrease over time, but moderate to severe sleep apnoea is nevertheless present in up to a third of patients in the chronic phase after an ischaemic stroke. Over the past few decades evidence suggests that treatment for sleep apnoea is feasible during the acute phase of stroke and might favourably affect recovery and long-term outcomes. Nevertheless, sleep apnoea still remains underdiagnosed and untreated in many cases, due to challenges in the detection and prediction of post-stroke sleep apnoea, uncertainty as to the optimal timing for its diagnosis, and a scarcity of clear treatment guidelines (ie, uncertainty on when to treat and the optimal treatment strategy). Moreover, the pathophysiology of sleep apnoea associated with stroke, the proportion of stroke survivors with obstructive and central sleep apnoea, and the temporal evolution of sleep apnoea subtypes following stroke remain to be clarified. To address these shortcomings, the management of sleep apnoea associated with stroke should be integrated into a multidisciplinary diagnostic, treatment, and follow-up strategy.
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Affiliation(s)
- Sébastien Baillieul
- Department of Neurology, Inselspital, University Hospital, Bern, Switzerland; Service Universitaire de Pneumologie Physiologie, Grenoble Alpes University Hospital, Grenoble, France; Inserm U1300, Grenoble Institute of Neurosciences, Université Grenoble Alpes, Grenoble, France
| | - Martijn Dekkers
- Department of Neurology, Inselspital, University Hospital, Bern, Switzerland
| | - Anne-Kathrin Brill
- Department of Pulmonary Medicine, Inselspital, University Hospital, Bern, Switzerland
| | - Markus H Schmidt
- Department of Neurology, Inselspital, University Hospital, Bern, Switzerland; Ohio Sleep Medicine Institute, Dublin, OH, USA
| | - Olivier Detante
- Stroke Unit, Neurology Department, Grenoble Alpes University Hospital, Grenoble, France; Inserm U1216, Grenoble Institute of Neurosciences, Université Grenoble Alpes, Grenoble, France
| | - Jean-Louis Pépin
- Service Universitaire de Pneumologie Physiologie, Grenoble Alpes University Hospital, Grenoble, France; Inserm U1300, Grenoble Institute of Neurosciences, Université Grenoble Alpes, Grenoble, France
| | - Renaud Tamisier
- Service Universitaire de Pneumologie Physiologie, Grenoble Alpes University Hospital, Grenoble, France; Inserm U1300, Grenoble Institute of Neurosciences, Université Grenoble Alpes, Grenoble, France
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24
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Javaheri S, Peker Y, Yaggi HK, Bassetti CLA. Obstructive sleep apnea and stroke: The mechanisms, the randomized trials, and the road ahead. Sleep Med Rev 2021; 61:101568. [PMID: 34906778 DOI: 10.1016/j.smrv.2021.101568] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/02/2021] [Accepted: 11/03/2021] [Indexed: 10/19/2022]
Abstract
When considered separately from cardiovascular disease, stroke is the third leading cause of death in the U.S. and is the leading cause of long-term disability in adults. New approaches that can be offered to the majority of ischemic stroke patients, can be continued throughout post-stroke care, can limit stroke severity, and can complement or even enhance rehabilitation, would transform ischemic stroke recovery. The treatment of obstructive sleep apnea (OSA) in patients with acute ischemic stroke may represent one such approach. This manuscript reviews the epidemiologic studies of the bidirectional association between OSA and stroke, and the mechanisms and molecular signatures of OSA leading to transient ischemic attack and stroke as well as the randomized controlled trials and observational cohort studies examining continuous positive airway treatment efficacy on the impact of stroke outcomes. Finally, the insights these studies provide on future research are also discussed.
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Affiliation(s)
- Shahrokh Javaheri
- Division of Pulmonary and Sleep Medicine, Bethesda North Hospital, Cincinnati, OH, USA; Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Cardiology, The Ohio State University, Columbus, OH, USA.
| | - Yüksel Peker
- Department of Pulmonary Medicine, Koc University School of Medicine, Istanbul, Turkey; Department of Molecular and Clinical Medicine/Cardiology, Sahlgrenska Academy, University of Gothenburg, Sweden; Department of Clinical Sciences, Respiratory Medicine and Allergology, Faculty of Medicine, Lund University, Lund, Sweden; Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - H Klar Yaggi
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA; Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
| | - Claudio L A Bassetti
- Department of Neurology, Inselspital, University of Bern, Switzerland; Department of Neurology, Sechenow University Faculty of Medicine, Moscow, Russia
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25
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Boulos MI, Kamra M, Colelli DR, Kirolos N, Gladstone DJ, Boyle K, Sundaram A, Hopyan JJ, Swartz RH, Mamdani M, Loong D, Isaranuwatchai W, Murray BJ, Thorpe KE. SLEAP SMART (Sleep Apnea Screening Using Mobile Ambulatory Recorders After TIA/Stroke): A Randomized Controlled Trial. Stroke 2021; 53:710-718. [PMID: 34628939 DOI: 10.1161/strokeaha.120.033753] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Poststroke/transient ischemic attack obstructive sleep apnea (OSA) is prevalent, linked with numerous unfavorable health consequences, but remains underdiagnosed. Reasons include patient inconvenience and costs associated with use of in-laboratory polysomnography (iPSG), the current standard tool. Fortunately, home sleep apnea testing (HSAT) can accurately diagnose OSA and is potentially more convenient and cost-effective compared with iPSG. Our objective was to assess whether screening for OSA in patients with stroke/transient ischemic attack using HSAT, compared with standard of care using iPSG, increased diagnosis and treatment of OSA, improved clinical outcomes and patient experiences with sleep testing, and was a cost-effective approach. METHODS We consecutively recruited 250 patients who had sustained a stroke/transient ischemic attack within the past 6 months. Patients were randomized (1:1) to use of (1) HSAT versus (2) iPSG. Patients completed assessments and questionnaires at baseline and 6-month follow-up appointments. Patients diagnosed with OSA were offered continuous positive airway pressure. The primary outcome was compared between study arms via an intention-to-treat analysis. RESULTS At 6 months, 94 patients completed HSAT and 71 patients completed iPSG. A significantly greater proportion of patients in the HSAT arm were diagnosed with OSA (48.8% versus 35.2%, P=0.04) compared with the iPSG arm. Furthermore, patients assigned to HSAT, compared with iPSG, were more likely to be prescribed continuous positive airway pressure (40.0% versus 27.2%), report significantly reduced sleepiness, and a greater ability to perform daily activities. Moreover, a significantly greater proportion of patients reported a positive experience with sleep testing in the HSAT arm compared with the iPSG arm (89.4% versus 31.1%). Finally, a cost-effectiveness analysis revealed that HSAT was economically attractive for the detection of OSA compared with iPSG. CONCLUSIONS In patients with stroke/transient ischemic attack, use of HSAT compared with iPSG increases the rate of OSA diagnosis and treatment, reduces daytime sleepiness, improves functional outcomes and experiences with sleep testing, and could be an economically attractive approach. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02454023.
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Affiliation(s)
- Mark I Boulos
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (M.I.B., M.K., D.R.C., N.K., D.J.G., K.B., A.S., J.J.H., R.H.S., B.J.M.).,Department of Medicine, Division of Neurology, University of Toronto, Ontario, Canada. (M.I.B., D.J.G., K.B., A.S., J.J.H., R.H.S., B.J.M.).,Sleep Laboratory, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (M.I.B., B.J.M.)
| | - Maneesha Kamra
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (M.I.B., M.K., D.R.C., N.K., D.J.G., K.B., A.S., J.J.H., R.H.S., B.J.M.)
| | - David R Colelli
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (M.I.B., M.K., D.R.C., N.K., D.J.G., K.B., A.S., J.J.H., R.H.S., B.J.M.)
| | - Nardin Kirolos
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (M.I.B., M.K., D.R.C., N.K., D.J.G., K.B., A.S., J.J.H., R.H.S., B.J.M.)
| | - David J Gladstone
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (M.I.B., M.K., D.R.C., N.K., D.J.G., K.B., A.S., J.J.H., R.H.S., B.J.M.).,Department of Medicine, Division of Neurology, University of Toronto, Ontario, Canada. (M.I.B., D.J.G., K.B., A.S., J.J.H., R.H.S., B.J.M.)
| | - Karl Boyle
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (M.I.B., M.K., D.R.C., N.K., D.J.G., K.B., A.S., J.J.H., R.H.S., B.J.M.).,Department of Medicine, Division of Neurology, University of Toronto, Ontario, Canada. (M.I.B., D.J.G., K.B., A.S., J.J.H., R.H.S., B.J.M.).,Stroke Medicine, Beaumont Hospital, Dublin, Ireland (K.B.)
| | - Arun Sundaram
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (M.I.B., M.K., D.R.C., N.K., D.J.G., K.B., A.S., J.J.H., R.H.S., B.J.M.).,Department of Medicine, Division of Neurology, University of Toronto, Ontario, Canada. (M.I.B., D.J.G., K.B., A.S., J.J.H., R.H.S., B.J.M.)
| | - Julia J Hopyan
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (M.I.B., M.K., D.R.C., N.K., D.J.G., K.B., A.S., J.J.H., R.H.S., B.J.M.).,Department of Medicine, Division of Neurology, University of Toronto, Ontario, Canada. (M.I.B., D.J.G., K.B., A.S., J.J.H., R.H.S., B.J.M.)
| | - Richard H Swartz
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (M.I.B., M.K., D.R.C., N.K., D.J.G., K.B., A.S., J.J.H., R.H.S., B.J.M.).,Department of Medicine, Division of Neurology, University of Toronto, Ontario, Canada. (M.I.B., D.J.G., K.B., A.S., J.J.H., R.H.S., B.J.M.)
| | - Muhammad Mamdani
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Ontario, Canada (M.M., D.L., W.I)
| | - Desmond Loong
- Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada. (D.L., W.I.).,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Ontario, Canada (M.M., D.L., W.I)
| | - Wanrudee Isaranuwatchai
- Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada. (D.L., W.I.).,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Ontario, Canada (M.M., D.L., W.I)
| | - Brian J Murray
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (M.I.B., M.K., D.R.C., N.K., D.J.G., K.B., A.S., J.J.H., R.H.S., B.J.M.).,Department of Medicine, Division of Neurology, University of Toronto, Ontario, Canada. (M.I.B., D.J.G., K.B., A.S., J.J.H., R.H.S., B.J.M.).,Sleep Laboratory, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (M.I.B., B.J.M.)
| | - Kevin E Thorpe
- Applied Health Research Centre & Dalla Lana School of Public Health, University of Toronto, Ontario, Canada. (K.E.T.)
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Malhotra A, Ayappa I, Ayas N, Collop N, Kirsch D, Mcardle N, Mehra R, Pack AI, Punjabi N, White DP, Gottlieb DJ. Metrics of sleep apnea severity: beyond the apnea-hypopnea index. Sleep 2021; 44:zsab030. [PMID: 33693939 PMCID: PMC8271129 DOI: 10.1093/sleep/zsab030] [Citation(s) in RCA: 155] [Impact Index Per Article: 51.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/31/2021] [Indexed: 12/13/2022] Open
Abstract
Obstructive sleep apnea (OSA) is thought to affect almost 1 billion people worldwide. OSA has well established cardiovascular and neurocognitive sequelae, although the optimal metric to assess its severity and/or potential response to therapy remains unclear. The apnea-hypopnea index (AHI) is well established; thus, we review its history and predictive value in various different clinical contexts. Although the AHI is often criticized for its limitations, it remains the best studied metric of OSA severity, albeit imperfect. We further review the potential value of alternative metrics including hypoxic burden, arousal intensity, odds ratio product, and cardiopulmonary coupling. We conclude with possible future directions to capture clinically meaningful OSA endophenotypes including the use of genetics, blood biomarkers, machine/deep learning and wearable technologies. Further research in OSA should be directed towards providing diagnostic and prognostic information to make the OSA diagnosis more accessible and to improving prognostic information regarding OSA consequences, in order to guide patient care and to help in the design of future clinical trials.
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Affiliation(s)
- Atul Malhotra
- Department of Medicine, University of California San Diego, La Jolla, CA
| | - Indu Ayappa
- Department of Medicine, Mt. Sinai, New York, NY
| | - Najib Ayas
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Nancy Collop
- Department of Medicine, Emory University, Atlanta, GA
| | - Douglas Kirsch
- Department of Medicine, Atrium Health Sleep Medicine, Atrium Health, Charlotte, NC
| | - Nigel Mcardle
- Department of Medicine, The University of Western Australia, Perth, Australia
| | - Reena Mehra
- Department of Medicine, Cleveland Clinic, Cleveland, OH
| | - Allan I Pack
- Department of Medicine, University of Pennsylvania, Philadelphia, PA
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Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52:e364-e467. [PMID: 34024117 DOI: 10.1161/str.0000000000000375] [Citation(s) in RCA: 1193] [Impact Index Per Article: 397.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Rimke AN, Ahmed SB, Turin TC, Pendharkar SR, Raneri JK, Lynch EJ, Hanly PJ. Recruitment of patients with chronic kidney disease and obstructive sleep apnoea for a clinical trial. J Sleep Res 2021; 30:e13384. [PMID: 33973687 DOI: 10.1111/jsr.13384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/05/2021] [Accepted: 04/19/2021] [Indexed: 11/27/2022]
Abstract
Obstructive sleep apnoea is common in chronic kidney disease (CKD) and may accelerate the decline in kidney function. Recruitment for a randomised controlled trial to address whether treatment of sleep apnoea with continuous positive airway pressure (CPAP) slows the progression of kidney failure may be challenging because sleep apnoea is often asymptomatic in this patient population. The present report outlines recruitment challenges and how to address them. Adult patients with CKD were recruited for a 12-month randomised, controlled, non-blinded, parallel clinical trial to evaluate the impact of CPAP therapy on kidney function. Patients completed a home sleep apnoea test and those that met pre-specified sleep apnoea and nocturnal hypoxaemia severity criteria were randomised to receive CPAP or no therapy. Although 1,665 patients were eligible to participate in the study over 3 years, only 57 (3.4%) were ultimately randomised. The sequential reasons (and number of patients) for recruitment failure were: no show at clinic appointment (137), insufficient recruiters to approach every eligible patient (461), on therapy for sleep apnoea (122), unable to provide informed consent (67), refused consent (645), home sleep apnoea test not completed (47) or inclusion criteria not met (116), and declined pre-randomisation education session (12). Many challenges limit effective recruitment, which may be addressed by hiring additional recruiters and increasing the awareness of sleep apnoea among patients with CKD. These findings can be used to improve recruitment strategies and the design of future studies.
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Affiliation(s)
- Alex N Rimke
- Sleep Centre, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada.,Libin Cardiovascular Institute of Alberta, Calgary, AB, Canada
| | - Sofia B Ahmed
- Libin Cardiovascular Institute of Alberta, Calgary, AB, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Kidney Disease Network, Calgary, AB, Canada
| | - Tanvir C Turin
- Department of Family Medicine, University of Calgary, Calgary, AB, Canada
| | - Sachin R Pendharkar
- Sleep Centre, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jill K Raneri
- Sleep Centre, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Emma J Lynch
- Sleep Centre, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Patrick J Hanly
- Sleep Centre, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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29
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Cai H, Wang XP, Yang GY. Sleep Disorders in Stroke: An Update on Management. Aging Dis 2021; 12:570-585. [PMID: 33815883 PMCID: PMC7990374 DOI: 10.14336/ad.2020.0707] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 07/07/2020] [Indexed: 12/18/2022] Open
Abstract
Stroke is a leading cause of disability and mortality all over the world. Due to an aging population, the incidence of stroke is rising significantly, which has led to devastating consequences for patients. In addition to traditional risk factors such as age, hypertension, hyperlipidemia, diabetes and atrial fibrillation, sleep disorders, as independent modifiable risk factors for stroke, have been highlighted increasingly. In this review, we provide an overview of common types of current sleep disturbances in cerebrovascular diseases, including insomnia, hypersomnia, breathing-related sleep disorders, and parasomnias. Moreover, evidence-based clinical therapeutic strategies and pitfalls of specific sleep disorders after stroke are discussed. We also review the neurobiological mechanisms of these treatments as well as their effects on stroke. Since depression after stroke is so prevalent and closely related to sleep disorders, treatments of post-stroke depression are also briefly mentioned in this review article.
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Affiliation(s)
- Hongxia Cai
- Department of Neurology, Tong-Ren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Xiao-Ping Wang
- Department of Neurology, Tong-Ren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Guo-Yuan Yang
- Med-X Research Institute and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China.
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30
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Sex-Specific Differential Responses of Circulating Biomarkers in Obstructive Sleep Apnea Treatment. A Post Hoc Analysis of a Randomized Controlled Trial. Ann Am Thorac Soc 2021; 17:605-613. [PMID: 31860326 DOI: 10.1513/annalsats.201908-593oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: Knowledge of sex-specific changes of cardiovascular biomarkers in response to continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea (OSA) is limited.Objectives: We hypothesized a differential sex-specific cardiovascular biomarker response with CPAP therapy for OSA.Methods: Participants with moderate-severe OSA (apnea-hypopnea index, 15 events/h) were randomized to CPAP versus sham and completed polysomnography and collection of biomarkers of inflammation (myeloperoxidase, fibrinogen, paraoxonase, interleukin [IL]-6, IL-6 soluble receptor, aryl esterase, oxidized low-density lipoprotein, lipoprotein A, plasminogen activator inhibitor 1, and F2-isoprostane urine/creatinine ratio) and vascular measures at baseline and 8 weeks of therapy with either CPAP (n = 72) or sham treatment (n = 70). Post hoc secondary analyses of sex-study arm interaction relative to change in inflammatory biomarkers were evaluated via linear regression with adjustment for baseline biomarker value, age, race, body mass, index, waist circumference, and CPAP adherence. Interactions were further evaluated via sex-stratified analyses.Results: The study sample comprised a total of 149 participants aged 50.8 ± 11.7 years; 55% were male, and 55% were white. Participants had a median apnea-hypopnea index of 26.3 events per hour (interquartile range, 13-37). There were substantial interactions between study arm and sex for myeloperoxidase, paraoxonase, and fibrinogen (P = 0.03, P = 0.03, and P = 0.08, respectively). No significant interactions were found for the vascular measures. Estimates were similar but with decreased power in sex-stratified analyses, with decreased biomarkers in women and increased biomarkers in men.Conclusions: Differential sex-specific responses to CPAP therapy for OSA were observed for circulating inflammatory biomarkers, which persisted after adjustment for confounders. These findings set the stage for validation studies and, if confirmed, biochemical pathway elucidation to inform sex-specific personalized treatment approaches.Clinical trial registered with www.clinicaltrials.gov (NCT00607893).
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Abstract
PURPOSE OF REVIEW Stroke and sleep apnea are highly prevalent conditions with a physiologically plausible bidirectional relationship. This review addresses prestroke sleep apnea, wake-up stroke and sleep apnea, and poststroke sleep apnea, with an attempt to highlight research published in the last 18 months. RECENT FINDINGS Sleep apnea is highly prevalent poststroke. Poststroke sleep apnea is associated with worse poststroke functional and cognitive outcomes and a higher risk of recurrent stroke. Physiologic tests are needed to diagnose sleep apnea in poststroke patients as sleep apnea questionnaires do not perform well in this population. The role of CPAP in poststroke management is not yet well established. SUMMARY Sleep apnea is a well established independent risk factor for stroke that confers an approximately two-fold increased risk of incident stroke. Sleep apnea is highly prevalent poststroke and is associated with worse outcomes after stroke. Sleep apnea is an attractive target for research addressing secondary stroke prevention and recovery.
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32
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Boulos MI, Dharmakulaseelan L, Brown DL, Swartz RH. Trials in Sleep Apnea and Stroke: Learning From the Past to Direct Future Approaches. Stroke 2020; 52:366-372. [PMID: 33349009 DOI: 10.1161/strokeaha.120.031709] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Few randomized controlled trials have evaluated the effectiveness of continuous positive airway pressure (CPAP) in reducing recurrent vascular events and mortality in poststroke obstructive sleep apnea (OSA). To date, results have been mixed, most studies were underpowered and definitive conclusions are not available. Using lessons learned from prior negative trials in stroke, we reappraise prior randomized controlled trials that examined the use of CPAP in treating poststroke OSA and propose the following considerations: (1) Intervention-based changes, such as ensuring that patients are using CPAP for at least 4 hours per night (eg, through use of improvements in CPAP technology that make it easier for patients to use), as well as considering alternative treatment strategies for poststroke OSA; (2) Population-based changes (ie, including stroke patients with severe and symptomatic OSA and CPAP noncompliers); and (3) Changes to timing of intervention and follow-up (ie, early initiation of CPAP therapy within the first 48 hours of stroke and long-term follow-up calculated in accordance with sample size to ensure adequate power). Given the burden of vascular morbidity and mortality in stroke patients with OSA, there is a strong need to learn from past negative trials and explore innovative stroke prevention strategies to improve stroke-free survival.
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Affiliation(s)
- Mark I Boulos
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (M.I.B., L.D., R.H.S.).,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute (M.I.B., L.D., R.H.S.), Sunnybrook Health Sciences Centre, Toronto, Canada.,Sleep Laboratory (M.I.B., R.H.S.), Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Laavanya Dharmakulaseelan
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (M.I.B., L.D., R.H.S.).,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute (M.I.B., L.D., R.H.S.), Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Devin L Brown
- Department of Neurology, University of Michigan, Ann Arbor (D.L.B.)
| | - Richard H Swartz
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (M.I.B., L.D., R.H.S.).,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute (M.I.B., L.D., R.H.S.), Sunnybrook Health Sciences Centre, Toronto, Canada.,Sleep Laboratory (M.I.B., R.H.S.), Sunnybrook Health Sciences Centre, Toronto, Canada
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33
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Lin HJ, Yeh JH, Hsieh MT, Hsu CY. Continuous positive airway pressure with good adherence can reduce risk of stroke in patients with moderate to severe obstructive sleep apnea: An updated systematic review and meta-analysis. Sleep Med Rev 2020; 54:101354. [DOI: 10.1016/j.smrv.2020.101354] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 04/23/2020] [Accepted: 04/24/2020] [Indexed: 01/23/2023]
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34
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Bernasconi C, Ott SR, Fanfulla F, Miano S, Horvath T, Seiler A, Cereda CW, Brill AK, Young P, Nobili L, Manconi M, Bassetti CLA. SAS CARE 2 - a randomized study of CPAP in patients with obstructive sleep disordered breathing following ischemic stroke or transient ischemic attack. Sleep Med X 2020; 2:100027. [PMID: 33870178 PMCID: PMC8041126 DOI: 10.1016/j.sleepx.2020.100027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 09/03/2020] [Accepted: 09/29/2020] [Indexed: 12/23/2022] Open
Abstract
Objective/background The benefit of Continuous Positive Airway Pressure (CPAP) treatment following ischemic stroke in patients with obstructive sleep-disordered breathing (SDB) is unclear. We set out to investigate this open question in a randomized controlled trial as part of the SAS-CARE study. Patients/methods. Non-sleepy patients (ESS < 10) with ischemic stroke or transient ischemic attack (TIA) and obstructive SDB (AHI ≥ 20) 3 months post-stroke were randomized 1:1 to CPAP treatment (CPAP+) or standard care. Primary outcome was the occurrence of vascular events (TIA/stroke, myocardial infarction/revascularization, hospitalization for heart failure or unstable angina) or death within 24 months post-stroke. Secondary outcomes included Modified Rankin Scale (mRS) and Barthel Index. Results Among 238 SAS-CARE patients 41 (17%) non-sleepy obstructive SDB patients were randomized to CPAP (n = 19) or standard care (n = 22). Most patients (80%) had stroke and were males (78%), mean age was 64 ± 7 years and mean NIHSS score 0.6 ± 1.0 (range: 0–5). The primary endpoint was met by one patient in the standard care arm (a new stroke). In an intent-to treat analysis disregarding adherence, this corresponds to an absolute risk difference of 4.5% or an NNT = 22. mRS and Barthel Index were stable and similar between arms. CPAP adherence was sufficient in 60% of evaluable patients at month 24. Conclusion No benefit of CPAP started three months post-stroke was found in terms of new cardio- and cerebrovascular events over 2 years. This may be related to the small size of this study, the mild stoke severity, the exclusion of sleepy patients, the delayed start of treatment, and the overall low event rate. No benefit of CPAP started 3 months post-stroke was found. A sufficient CPAP compliance was observed over 2 years in 60% of patients. Studies of CPAP in mild stroke need to be large and include long-term outcomes.
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Affiliation(s)
- C Bernasconi
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - S R Ott
- Department of Pulmonary Medicine, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.,Sleep-Wake-Epilepsy Center, Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.,Pulmonary and Sleep Medicine, St. Claraspital, Basel, Switzerland
| | - F Fanfulla
- Sleep Medicine, Neurocenter of the Southern Switzerland, Regional Hospital of Lugano, Lugano, Switzerland.,Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland.,Sleep Medicine Unit, Istituti Clinici Scientifici Maugeri, Pavia, Italy
| | - S Miano
- Sleep Medicine, Neurocenter of the Southern Switzerland, Regional Hospital of Lugano, Lugano, Switzerland.,Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - T Horvath
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - A Seiler
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - C W Cereda
- Stroke Center EOC, Neurocenter of the Southern Switzerland, Regional Hospital of Lugano, Lugano, Switzerland
| | - A-K Brill
- Department of Pulmonary Medicine, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.,Sleep-Wake-Epilepsy Center, Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - P Young
- University Hospital Münster, Department of Neurology, Münster, Germany
| | - L Nobili
- Department of Neurology, Ospedale Niguarda, Milano, Italy.,DINOGMI, University of Genoa, Genoa, Italy
| | - M Manconi
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.,Sleep Medicine, Neurocenter of the Southern Switzerland, Regional Hospital of Lugano, Lugano, Switzerland.,Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - C L A Bassetti
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.,Sleep-Wake-Epilepsy Center, Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.,Neurology Department, Sechenov First Moscow State Medical University, Moscow, Russia
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35
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Dunietz GL, Chervin RD, Burke JF, Braley TJ. Obstructive sleep apnea treatment disparities among older adults with neurological disorders. Sleep Health 2020; 6:534-540. [PMID: 32331862 PMCID: PMC7529672 DOI: 10.1016/j.sleh.2020.01.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 01/09/2020] [Accepted: 01/13/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The objective of the study was to characterize obstructive sleep apnea treatment patterns among older Americans with neurological conditions. SETTING AND PARTICIPANTS Claims data from a 5% fee-for-service sample of Medicare beneficiaries were analyzed to determine the proportion of older adults with OSA who received and were adherent to continuous positive airway pressure therapy and examine potential gaps in OSA care among neurological populations. Logistic regression was used to determine whether gender or race/ethnicity modified the associations between neurological morbidities and OSA treatment or adherence. RESULTS Data from n = 102,618 beneficiaries with OSA were identified. The prevalence of stroke, cognitive disorders, or Parkinson's disease in this sample was 7%, 3%, and 2% respectively. Overall, OSA-diagnosed individuals (73%) obtained treatment, and most treated were adherent to CPAP (72%). Lower proportions of OSA treatment and adherence were observed in neurological conditions, particularly stroke. In logistic regression models, gender and race/ethnicity each modified associations between neurological comorbidity and OSA treatment and adherence. Women as compared to men with a given neurological condition were uniformly less likely to receive CPAP or adhere to treatment (P < .01 for each condition). Similarly, in comparison to whites with the same neurological condition, OSA treatment was significantly lower among all other races with stroke, and among blacks with cognitive disorders. CONCLUSIONS Older women and minorities with neurological conditions may be more vulnerable to gaps in OSA care. Targeted strategies to improve treatment disparities and neurological outcomes in older adults could be informed by these data.
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Affiliation(s)
- Galit Levi Dunietz
- Division of Sleep Medicine, Department of Neurology, University of Michigan, Ann Arbor, Michigan.
| | - Ronald D Chervin
- Division of Sleep Medicine, Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - James F Burke
- Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Tiffany J Braley
- Department of Neurology, University of Michigan, Ann Arbor, Michigan
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Pengo MF, Soranna D, Giontella A, Perger E, Mattaliano P, Schwarz EI, Lombardi C, Bilo G, Zambon A, Steier J, Parati G, Minuz P, Fava C. Obstructive sleep apnoea treatment and blood pressure: which phenotypes predict a response? A systematic review and meta-analysis. Eur Respir J 2020; 55:13993003.01945-2019. [PMID: 32079643 DOI: 10.1183/13993003.01945-2019] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 02/06/2020] [Indexed: 11/05/2022]
Abstract
The treatment for obstructive sleep apnoea (OSA) with continuous positive airway pressure (CPAP) or mandibular advancement devices (MADs) is associated with blood pressure (BP) reduction; however, the overall effect is modest. The aim of this systematic review and meta-analysis of randomised controlled trials (RCTs) comparing the effect of such treatments on BP was to identify subgroups of patients who respond best to treatment.The article search was performed in three different databases with specific search terms and selection criteria. From 2289 articles, we included 68 RCTs that compared CPAP or MADs with either passive or active treatment. When all the studies were pooled together, CPAP and MADs were associated with a mean BP reduction of -2.09 (95% CI -2.78- -1.40) mmHg for systolic BP and -1.92 (95% CI -2.40- -1.43) mmHg for diastolic BP and -1.27 (95% CI -2.34- -0.20) mmHg for systolic BP and -1.11 (95% CI -1.82- -0.41) mmHg for diastolic BP, respectively. The subgroups of patients who showed a greater response were those aged <60 years (systolic BP -2.93 mmHg), with uncontrolled BP at baseline (systolic BP -4.14 mmHg) and with severe oxygen desaturations (minimum arterial oxygen saturation measured by pulse oximetry <77%) at baseline (24-h systolic BP -7.57 mmHg).Although this meta-analysis shows that the expected reduction of BP by CPAP/MADs is modest, it identifies specific characteristics that may predict a pronounced benefit from CPAP in terms of BP control. These findings should be interpreted with caution; however, they are particularly important in identifying potential phenotypes associated with BP reduction in patients treated for OSA.
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Affiliation(s)
- Martino F Pengo
- Dept of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Davide Soranna
- Dept of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy.,These authors are joint co-authors
| | - Alice Giontella
- Section of General Medicine and Hypertension, Dept of Medicine, University of Verona, Verona, Italy.,These authors are joint co-authors
| | - Elisa Perger
- Dept of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Paola Mattaliano
- Dept of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Esther Irene Schwarz
- Dept of Pulmonology and Sleep Disorders Centre, University Hospital of Zurich, Zurich, Switzerland
| | - Carolina Lombardi
- Dept of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Grzegorz Bilo
- Dept of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Antonella Zambon
- Dept of Statistics and Quantitative Methods, Università di Milano-Bicocca, Milan, Italy
| | - Joerg Steier
- CHAPS, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Gianfranco Parati
- Dept of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy.,Dept of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Pietro Minuz
- Section of General Medicine and Hypertension, Dept of Medicine, University of Verona, Verona, Italy
| | - Cristiano Fava
- Section of General Medicine and Hypertension, Dept of Medicine, University of Verona, Verona, Italy
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Bassetti CLA, Randerath W, Vignatelli L, Ferini-Strambi L, Brill AK, Bonsignore MR, Grote L, Jennum P, Leys D, Minnerup J, Nobili L, Tonia T, Morgan R, Kerry J, Riha R, McNicholas WT, Papavasileiou V. EAN/ERS/ESO/ESRS statement on the impact of sleep disorders on risk and outcome of stroke. Eur Respir J 2020; 55:13993003.01104-2019. [PMID: 32317355 DOI: 10.1183/13993003.01104-2019] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 09/12/2019] [Indexed: 12/26/2022]
Abstract
Sleep disorders are highly prevalent in the general population and may be linked in a bidirectional fashion to stroke, which is one of the leading causes of morbidity and mortality.Four major scientific societies established a task force of experts in neurology, stroke, respiratory medicine, sleep medicine and methodology, to critically evaluate the evidence regarding potential links and the impact of therapy. 13 research questions were evaluated in a systematic literature search using a stepwise hierarchical approach: first, systematic reviews and meta-analyses; second, primary studies post-dating the systematic reviews/meta-analyses. A total of 445 studies were evaluated and 88 included. Statements were generated regarding current evidence and clinical practice.Severe obstructive sleep apnoea (OSA) doubles the risk for incident stroke, especially in young to middle-aged patients. Continuous positive airway pressure (CPAP) may reduce stroke risk, especially in treatment-compliant patients. The prevalence of OSA is high in stroke patients and can be assessed by polygraphy. Severe OSA is a risk factor for recurrence of stroke and may be associated with stroke mortality, while CPAP may improve stroke outcome. It is not clear if insomnia increases stroke risk, while pharmacotherapy of insomnia may increase it. Periodic limb movements in sleep (PLMS), but not restless limb syndrome (RLS), may be associated with an increased risk of stroke. Preliminary data suggest a high frequency of post-stroke insomnia and RLS and their association with a less favourable stroke outcome, while treatment data are scarce.Overall, the evidence base is best for OSA relationship with stroke and supports active diagnosis and therapy. Research gaps remain especially regarding insomnia and RLS/PLMS relationships with stroke.
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Affiliation(s)
- Claudio L A Bassetti
- Neurology Dept, Medical Faculty, University Hospital, Bern, Switzerland.,Dept of Neurology, Sechenov First Moscow State Medical University, Moscow, Russia.,Co-shared first authorship
| | - Winfried Randerath
- Bethanien Hospital, Clinic of Pneumology and Allergology, Center for Sleep Medicine and Respiratory Care, Institute of Pneumology at the University of Cologne, Solingen, Germany.,Co-shared first authorship
| | - Luca Vignatelli
- Servizio di Epidemiologia e Biostatistica IRCCS, Istituto delle Scienze Neurologiche di Bologna Ospedale Bellaria, Bologna, Italy
| | - Luigi Ferini-Strambi
- Dept of Neurology OSR-Turro, Sleep Disorder Center, Vita-Salute San Raffaele University, Milan, Italy
| | - Anne-Kathrin Brill
- Dept of Pulmonary Medicine, University and University Hospital Bern, Bern, Switzerland
| | - Maria R Bonsignore
- PROMISE Dept, Division of Respiratory Medicine, DiBiMIS, University of Palermo and IBIM-CNR, Palermo, Italy
| | - Ludger Grote
- Sleep Disorders Center, Dept of Pulmonary Medicine, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Poul Jennum
- Danish Center for Sleep Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Didier Leys
- Dept of Neurology, University of Lille, Lille, France
| | - Jens Minnerup
- Dept of Neurology and Institute for Translational Neurology, University of Muenster, Muenster, Germany
| | - Lino Nobili
- Child Neuropsychiatry Unit, Gaslini Institute DINOGMI, University of Genova, Genoa, Italy
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, Universtity of Bern, Bern, Switzerland
| | - Rebecca Morgan
- Dept of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Joel Kerry
- Library and Information Service, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Renata Riha
- Sleep Research Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.,Dept of Sleep Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Walter T McNicholas
- Dept of Respiratory and Sleep Medicine, St. Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland.,First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Co-shared senior authorship
| | - Vasileios Papavasileiou
- Leeds Teaching Hospital NHS Trust, Leeds, UK.,Medical School, University of Leeds, Leeds, UK.,Co-shared senior authorship
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Bassetti CLA, Randerath W, Vignatelli L, Ferini‐Strambi L, Brill A, Bonsignore MR, Grote L, Jennum P, Leys D, Minnerup J, Nobili L, Tonia T, Morgan R, Kerry J, Riha R, McNicholas WT, Papavasileiou V. EAN/ERS/ESO/ESRS statement on the impact of sleep disorders on risk and outcome of stroke. Eur J Neurol 2020; 27:1117-1136. [DOI: 10.1111/ene.14201] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 03/04/2020] [Indexed: 02/06/2023]
Affiliation(s)
- C. L. A. Bassetti
- Neurology Department Medical Faculty University Hospital Bern Switzerland
- Department of Neurology Sechenov First Moscow State Medical University Moscow Russia
| | - W. Randerath
- Clinic of Pneumology and Allergology Center for Sleep Medicine and Respiratory Care Bethanien Hospital Institute of Pneumology at the University of Cologne Solingen Germany
| | - L. Vignatelli
- Servizio di Epidemiologia e Biostatistica IRCCS Istituto delle Scienze Neurologiche di Bologna Ospedale Bellaria BolognaItaly
| | - L. Ferini‐Strambi
- Department of Neurology OSR‐Turro Sleep Disorder Center Vita‐Salute San Raffaele University Milan Italy
| | - A.‐K. Brill
- Department of Pulmonary Medicine University and University Hospital Bern Bern Switzerland
| | - M. R. Bonsignore
- PROMISE Department Division of Respiratory Medicine DiBiMIS University of Palermo and IBIM‐CNR Palermo Italy
| | - L. Grote
- Sleep Disorders Center Department of Pulmonary Medicine Sahlgrenska University Hospital Göteborg Sweden
| | - P. Jennum
- Danish Center for Sleep Medicine Rigshospitalet Copenhagen Denmark
| | - D. Leys
- Department of Neurology University of Lille Lille France
| | - J. Minnerup
- Department of Neurology and Institute for Translational Neurology University of Muenster Muenster Germany
| | - L. Nobili
- Child Neuropsychiatry Unit Gaslini Institute DINOGMI University of Genova Genoa Italy
| | - T. Tonia
- Institute of Social and Preventive Medicine Universtity of Bern Bern Switzerland
| | - R. Morgan
- Department of Health Research Methods, Evidence, and Impact McMaster University Hamilton ON Canada
| | - J. Kerry
- Library and Information Service Leeds Teaching Hospitals NHS Trust LeedsUK
| | - R. Riha
- Sleep Research Unit Centre for Clinical Brain Sciences University of Edinburgh EdinburghUK
- Department of Sleep Medicine Royal Infirmary of Edinburgh Edinburgh UK
| | - W. T. McNicholas
- Department of Respiratory and Sleep Medicine St Vincent’s University Hospital DublinIreland
- School of Medicine University College Dublin Dublin Ireland
- First Affiliated Hospital of Guangzhou Medical University Guangzhou China
| | - V. Papavasileiou
- Leeds Teaching Hospital NHS Trust LeedsUK
- Medical School University of Leeds Leeds UK
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Billings ME, Lévy P, Ayas N. Suboptimal CPAP adherence: half a loaf is better than no bread at all. Eur Respir J 2020; 55:55/3/2000144. [PMID: 32198273 DOI: 10.1183/13993003.00144-2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 01/23/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Martha E Billings
- Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | | | - Najib Ayas
- Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada
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Rogers AJ, Kaplan I, Chung A, McFarlane SI, Jean-Louis G. Obstructive Sleep Apnea Risk and Stroke among Blacks with Metabolic Syndrome: Results from Metabolic Syndrome Outcome (MetSO) Registry. INTERNATIONAL JOURNAL OF CLINICAL RESEARCH & TRIALS 2020; 5:143. [PMID: 32587931 PMCID: PMC7316191 DOI: 10.15344/2456-8007/2020/143] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The American Stroke Association estimates that stroke is the fifth leading cause of death in the United States. According to the Center for Disease Control and Prevention someone in the United States has a stoke every 40 seconds, affecting more than 795,000 people of which 140,000 result in death [1]. Emerging evidence suggests that obstructive sleep apnea (OSA) is a strong risk factor for stroke. This study using The Metabolic Syndrome Outcome (MetSO) registry explored whether blacks at risk for obstructive sleep apnea (OSA) are at greater risk for a stroke. METHOD The present study utilized data from the MetSO study, an NIH-funded cohort study of blacks with metabolic syndrome (MetS). Patients were diagnosed with MetS using standard criteria articulated in the joint interim statement for harmonizing the MetS. The study assessed OSA risk using the Apnea Risk Evaluation System (ARES); defining high risk as a total ARES score ≥6. Data was coded and analyzed by an experienced statistician using SPSS 20.0. RESULTS A total of 1035 participants were screened for MetS in the MetSO registry. During the data collection period 875 participants were enrolled during the time of analysis. The average age of the sample was 62±14 years (range: 20-97); 71% were female, and all were of black race/ethnicity. Seventy-one percent reported finishing high school, and 43% reported annual income <10K. Descriptive analyses showed 93% of the participants were diagnosed with hypertension; 61%, diabetes; 72%, dyslipidemia; 90% were overweight/obese; 33% had a history of heart disease and 10% had a stroke history. Using the ARES screener, we estimated that 48% were at high risk for OSA. Logistic regression analysis, adjusting for age and gender, showed that patients at high risk for OSA had a nearly three-fold increase in the odds of having a stroke (OR = 2.79, 95% CI: 1.64-4.73). CONCLUSION In the MetSO registry, a cohort of blacks with MetS, the prevalence of stroke is greater than in the general US population. Blacks at risk for OSA are particularly vulnerable to experiencing a stroke.
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Affiliation(s)
- April J. Rogers
- St. John’s University, Division of Health and Human Services, College of Professional Studies, Queens, New York, USA
| | - Ian Kaplan
- SUNY Down State Medical, Department of Internal Medicine Center Brooklyn, New York, USA
| | - Alicia Chung
- Center for Healthful Behavior Change (CHBC), Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Samy I. McFarlane
- SUNY Down State Medical, Department of Internal Medicine Center Brooklyn, New York, USA
| | - Girardin Jean-Louis
- Center for Healthful Behavior Change (CHBC), Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
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Predictors of in-laboratory polysomnography attendance in a cohort of patients with stroke or TIA. Sleep Med 2019; 66:159-164. [PMID: 31877507 DOI: 10.1016/j.sleep.2019.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 10/03/2019] [Accepted: 10/04/2019] [Indexed: 02/07/2023]
Abstract
STUDY OBJECTIVES After cerebrovascular events, obstructive sleep apnea (OSA) is associated with poor functional outcomes, an increased risk of recurrent stroke, and mortality. Although the significant under-diagnosis of OSA is likely multifactorial in nature, factors associated with attendance at in-laboratory polysomnography (iPSG) are poorly understood. We evaluated demographic, lifestyle, and clinical variables that predicted attendance at iPSG in a cohort of patients with stroke and transient ischemic attack (TIA) enrolled in a clinical research study. METHODS Demographic, lifestyle, and clinical variables were summarized for the patients who did and did not attend iPSG. Multivariable binary logistic regression analyses were performed to examine four models that thematically aggregated predictors expected to relate to attendance. Further, t-tests for continuous variables, and chi-squared tests for categorical variables, were performed to uncover differences between the two groups. RESULTS In the 122 participants included in our analyses, mean age was 66.6 ± 15.7 (64.8% males) with only 59.0% of participants attending iPSG. Only Model 1, which investigated the impact of demographic, lifestyle, and cognitive status, was significant (χ2 = 35.31, p < 0.001). Among our variables, (1) younger age, (2) better cognition, (3) higher level of education, and (4) never-smoking status significantly predicted attendance at iPSG. CONCLUSION By understanding the relationship between variables that significantly predict attendance, we hope our results will translate into practices that promote iPSG attendance, which may help improve outcomes in the stroke/TIA population. CLINICAL TRIALS SLEep APnea Screening Using Mobile Ambulatory Recorders After TIA/Stroke (SLEAP SMART) (NCT02454023); https://clinicaltrials.gov/ct2/show/NCT02454023.
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Abstract
PURPOSE OF REVIEW Obstructive sleep apnea (OSA) is increasing in prevalence. The intermittent hypoxia of OSA has wide-ranging effects on a patient's general health outcomes. However, gold-standard investigations and treatment are expensive and a significant burden on patients. Therefore, OSA research remains focused on improving the means of diagnosing and treating OSA, in high-risk-associated conditions. This review is to provide an update on the advances in the field of OSA. RECENT FINDINGS There has been recent debate about the best practice for diagnosis and treatment of OSA. Further work has been done on conditions associated with OSA including hypertension, atherosclerosis, various types of dementia and intracranial aneurysms. Inflammatory and vascular risk factors associated with OSA increase stroke risk and alter outcomes for recovery. OSA should definitely be considered in patients presenting with nonarteritic anterior ischemic optic neuropathy, and perhaps those with intracranial hypertension. SUMMARY Newer home-based sleep-apnea testing can be implemented via physician clinics, with oversight by a certified sleep physician. Although continuous positive airway pressure (CPAP) is the gold-standard, management should include diet and exercise. It is important to test for, and treat OSA in patients with a range of neurological diseases. However, further studies into the long-term impact of CPAP on health outcomes are still needed.
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Lisabeth LD, Sánchez BN, Lim D, Chervin RD, Case E, Morgenstern LB, Tower S, Brown DL. Sleep-disordered breathing and poststroke outcomes. Ann Neurol 2019; 86:241-250. [PMID: 31155749 PMCID: PMC7549189 DOI: 10.1002/ana.25515] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/29/2019] [Accepted: 05/31/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To examine the association between sleep-disordered breathing and stroke outcomes, and determine the contribution of sleep-disordered breathing to outcome disparities in Mexican Americans. METHODS Ischemic stroke patients (n = 995), identified from the population-based Brain Attack Surveillance in Corpus Christi Project (2010-2015), were offered participation in a sleep-disordered breathing study including a home sleep apnea test (ApneaLink Plus). Sleep-disordered breathing (respiratory event index ≥10) was determined soon after stroke. Neurologic, functional, cognitive, and quality of life outcomes were assessed at 90 days poststroke. Regression models were used to assess associations between sleep-disordered breathing and outcomes, adjusted for sociodemographics, prestroke function and cognition, health-risk behaviors, stroke severity, and vascular risk factors. RESULTS Median age was 67 years (interquartile range [IQR] = 59-78); 62.1% were Mexican American. Median respiratory event index was 14 (IQR = 6-25); 62.8% had sleep-disordered breathing. Sleep-disordered breathing was associated with worse functional outcome (mean difference in activities of daily living/instrumental activities of daily living score = 0.15, 95% confidence interval [CI] = 0.01-0.28) and cognitive outcome (mean difference in modified Mini-Mental State Examination = -2.66, 95% CI = -4.85 to -0.47) but not neurologic or quality of life outcomes. Sleep-disordered breathing accounted for 9 to 10% of ethnic differences in functional and cognitive outcome and was associated with cognitive outcome more strongly for Mexican Americans (β = -3.97, 95% CI = -6.63 to -1.31) than non-Hispanic whites (β = -0.40, 95% CI = -4.18 to 3.39, p-interaction = 0.15). INTERPRETATION Sleep-disordered breathing is associated with worse functional and cognitive function at 90 days poststroke. These outcomes are reasonable endpoints for future trials of sleep-disordered breathing treatment in stroke. If effective, sleep-disordered breathing treatment may somewhat lessen ethnic stroke outcome disparities. ANN NEUROL 2019;86:241-250.
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Affiliation(s)
- Lynda D Lisabeth
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI
- Stroke Program, University of Michigan Health System, Ann Arbor, MI
| | - Brisa N Sánchez
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - David Lim
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Ronald D Chervin
- Michael S. Aldrich Sleep Disorders Laboratory, University of Michigan Health System, Ann Arbor, MI
| | - Erin Case
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI
| | - Lewis B Morgenstern
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI
- Stroke Program, University of Michigan Health System, Ann Arbor, MI
| | | | - Devin L Brown
- Stroke Program, University of Michigan Health System, Ann Arbor, MI
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Parasram M, Segal AZ. Sleep Disorders and Stroke: Does Treatment of Obstructive Sleep Apnea Decrease Risk of Ischemic Stroke? Curr Treat Options Neurol 2019; 21:29. [PMID: 31231783 DOI: 10.1007/s11940-019-0575-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE OF REVIEW This review aims to support obstructive sleep apnea (OSA) as a risk factor for ischemic stroke, review treatment strategies for OSA, provide a comprehensive review of clinical data on OSA treatment and ischemic stroke risk, and to critically assess if treatment of OSA decreases the risk of ischemic stroke and if treatment improves outcomes and subsequent ischemic stroke risk in post-stroke patients. RECENT FINDINGS Several observational studies, randomized controlled trials (RCTs), and meta-analyses have examined the risk of ischemic stroke and cardiovascular events in patients with OSA and have also examined continuous positive airway pressure (CPAP) treatment in these patients. Observational studies have shown an increased risk of ischemic stroke in patients with untreated OSA when compared with patients treated with CPAP; however, results are not statistically significant. RCTs and meta-analyses have shown no significant ischemic stroke risk reduction in CPAP treated patients with OSA. Several studies have shown improved outcomes in post-stroke patients with OSA treated with CPAP; however, few data is available for subsequent ischemic stroke risk reduction. Further research is needed for surgical treatment of OSA and assessment of ischemic stroke risk. OSA is associated with increased risk of ischemic stroke, and OSA should be treated with the appropriate therapy. While the current data is promising, more studies are necessary to state whether treatment of OSA reduces ischemic stroke risk and subsequent ischemic stroke risk. A practical approach to the sleep disorder evaluation and treatment of patients with cerebrovascular disease is outlined.
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Affiliation(s)
- Melvin Parasram
- Department of Neurology, Weill Cornell Medicine, 520 East 70th Street Starr-607, New York, NY, 10021, USA
| | - Alan Z Segal
- Department of Neurology, Weill Cornell Medicine, 520 East 70th Street Starr-607, New York, NY, 10021, USA.
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Lau HL, Rundek T, Ramos AR. Sleep and Stroke: New Updates on Epidemiology, Pathophysiology, Assessment, and Treatment. CURRENT SLEEP MEDICINE REPORTS 2019; 5:71-82. [PMID: 31850157 PMCID: PMC6916645 DOI: 10.1007/s40675-019-00142-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW This review aims to discuss the most recent data on sleep disorders and stroke, highlighting relevant findings for the practicing neurologist or health providers who encounter patients with sleep disorders and stroke. RECENT FINDINGS Sleep apnea and abnormal sleep duration have the strongest association with stroke risk. Possible mechanisms include non-dipping of blood pressure during sleep, hypoxemia or reoxygenation leading to sympathetic activation, hypertension, atrial fibrillation and impaired cerebral hemodynamics. Treatment studies suggest that continuous positive airway pressure (CPAP) for sleep apnea could improve primary prevention of stroke, but data is equivocal for secondary prevention. However, CPAP could improve functional outcomes after stroke. SUMMARY Sleep disorders present an opportunity to improve stroke risk and functional outcomes. However, new strategies are needed to determine the patients at high-risk who would most likely benefit from targeted care. Novel methods for phenotyping sleep disorders could provide personalized stroke care to improve clinical outcomes and public health strategies.
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Affiliation(s)
- H Lee Lau
- Departments of Neurology, Miller School of Medicine University of Miami, Miami, Florida, USA
| | - Tanja Rundek
- Departments of Neurology, Miller School of Medicine University of Miami, Miami, Florida, USA
| | - Alberto R Ramos
- Departments of Neurology, Miller School of Medicine University of Miami, Miami, Florida, USA
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Gregori-Pla C, Delgado-Mederos R, Cotta G, Giacalone G, Maruccia F, Avtzi S, Prats-Sánchez L, Martínez-Domeño A, Camps-Renom P, Martí-Fàbregas J, Durduran T, Mayos M. Microvascular cerebral blood flow fluctuations in association with apneas and hypopneas in acute ischemic stroke. NEUROPHOTONICS 2019; 6:025004. [PMID: 31037244 PMCID: PMC6477863 DOI: 10.1117/1.nph.6.2.025004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 04/04/2019] [Indexed: 06/09/2023]
Abstract
In a pilot study on acute ischemic stroke (AIS) patients, unexpected periodic fluctuations in microvascular cerebral blood flow (CBF) had been observed. Motivated by the relative lack of information about the impact of the emergence of breathing disorders in association with stroke on cerebral hemodynamics, we hypothesized that these fluctuations are due to apneic and hypopneic events. A total of 28 patients were screened within the first week after stroke with a pulse oximeter. Five (18%) showed fluctuations of arterial blood oxygen saturation ( ≥ 3 % ) and were included in the study. Near-infrared diffuse correlation spectroscopy (DCS) was utilized bilaterally to measure the frontal lobe CBF alongside respiratory polygraphy. Biphasic CBF fluctuations were observed with a bilateral increase of 27.1 % ± 17.7 % and 29.0 % ± 17.4 % for the ipsilesional and contralesional hemispheres, respectively, and a decrease of - 19.3 % ± 9.1 % and - 21.0 % ± 8.9 % for the ipsilesional and contralesional hemispheres, respectively. The polygraph revealed that, in general, the fluctuations were associated with apneic and hypopneic events. This study motivates us to investigate whether the impact of altered respiratory patterns on cerebral hemodynamics can be detrimental in AIS patients.
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Affiliation(s)
- Clara Gregori-Pla
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Castelldefels (Barcelona), Spain
| | - Raquel Delgado-Mederos
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Department of Neurology (Stroke Unit), Barcelona, Spain
| | - Gianluca Cotta
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Castelldefels (Barcelona), Spain
| | - Giacomo Giacalone
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Castelldefels (Barcelona), Spain
- San Raffaele Scientific Institute, Milan, Italy
| | - Federica Maruccia
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Castelldefels (Barcelona), Spain
- Universitat Autònoma de Barcelona, Neurotraumatology and Neurosurgery Research Unit, Vall d’Hebron University Research Institute, Barcelona, Spain
| | - Stella Avtzi
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Castelldefels (Barcelona), Spain
| | - Luís Prats-Sánchez
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Department of Neurology (Stroke Unit), Barcelona, Spain
| | - Alejandro Martínez-Domeño
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Department of Neurology (Stroke Unit), Barcelona, Spain
| | - Pol Camps-Renom
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Department of Neurology (Stroke Unit), Barcelona, Spain
| | - Joan Martí-Fàbregas
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Department of Neurology (Stroke Unit), Barcelona, Spain
| | - Turgut Durduran
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Castelldefels (Barcelona), Spain
- Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain
| | - Mercedes Mayos
- Hospital de la Santa Creu i Sant Pau, Sleep Unit, Department of Respiratory Medicine, Barcelona, Spain
- CIBER Enfermedades Respiratorias (CB06/06), Madrid, Spain
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McNicholas WT. Obstructive sleep apnoea and comorbidity - an overview of the association and impact of continuous positive airway pressure therapy. Expert Rev Respir Med 2019; 13:251-261. [PMID: 30691323 DOI: 10.1080/17476348.2019.1575204] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Obstructive sleep apnoea (OSA) is highly prevalent and there is considerable evidence supporting an independent association with a wide range of co-morbidities including cardiovascular, endocrine and metabolic, neuropsychiatric, pulmonary, and renal. Areas covered: A PubMed search of all the recent literature relating to OSA and co-morbidities was undertaken to critically evaluate the potential relationships and possible benefit of continuous positive airway pressure (CPAP) therapy. Expert commentary: The evidence supporting an independent association is stronger for some co-morbidities than others and in cardiovascular diseases is strongest for hypertension and atrial fibrillation. Potential mechanisms include intermittent hypoxia, fluctuating intrathoracic pressure, and recurring micro-arousals that trigger cell and molecular consequences including sympathetic excitation, systemic inflammation and oxidative stress, in addition to metabolic and endothelial dysfunction. Different mechanisms may predominate in individual co-morbidities. Recent long term randomised controlled trials have cast doubt on benefits to co-morbidities from CPAP therapy of OSA, especially where co-morbidities are already established. However, benefits may result in patients who are compliant with therapy and further research is required to clearly establish the role of OSA therapy in both primary and secondary prevention of co-morbidities.
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Affiliation(s)
- Walter T McNicholas
- a Department of Respiratory and Sleep Medicine, St. Vincent's Hospital Group and School of Medicine , University College Dublin , Dublin , Ireland.,b First Affiliated Hospital of Guangzhou Medical University , Guangzhou , China
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Catalan-Serra P, Campos-Rodriguez F, Reyes-Nuñez N, Selma-Ferrer MJ, Navarro-Soriano C, Ballester-Canelles M, Soler-Cataluña JJ, Roman-Sanchez P, Almeida-Gonzalez CV, Martinez-Garcia MA. Increased Incidence of Stroke, but Not Coronary Heart Disease, in Elderly Patients With Sleep Apnea. Stroke 2019; 50:491-494. [DOI: 10.1161/strokeaha.118.023353] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
The influence of age on the relationship between obstructive sleep apnea (OSA) and the incidence of hard cardiovascular events remains controversial. We sought to analyze the relationship between OSA and the incidence of stroke and coronary heart disease in a large cohort of elderly patients, as well as to investigate the role of continuous positive airway pressure (CPAP) treatment in these associations.
Methods—
Post hoc analysis of a prospective observational study of consecutive patients ≥65 years studied for OSA suspicion at 2 Spanish University Hospitals. Patients with an apnea-hypopnea index (AHI) <15 were the reference group. OSA was defined by an AHI ≥15 and classified as untreated (CPAP not prescribed or compliance <4 hours/day), mild-moderate (AHI 15–29), untreated severe (AHI ≥30), and CPAP-treated (AHI ≥15 and CPAP compliance ≥4 hours/day).
Results—
859 and 794 elderly patients were included in the stroke and coronary heart disease analyses, respectively. The median (interquartile range) follow-up was 72 (50–88.5) and 71 (51.5–89) months, respectively. Compared with the reference group, the fully adjusted hazard ratios for the incidence of stroke were 3.42 (95% CI, 1.37–8.52), 1.02 (95% CI, 0.41–2.56), and 1.76 (95% CI, 0.62–4.97) for the untreated severe OSA group, CPAP-treated group, and untreated mild-moderate OSA group, respectively. No associations were shown between any of the different OSA groups and coronary heart disease incidence.
Conclusions—
The incidence of stroke, but not coronary heart disease, is increased in elderly patients with untreated severe OSA. Adequate CPAP treatment may reduce this risk.
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Affiliation(s)
- Pablo Catalan-Serra
- From the Respiratory Department, Hospital Arnau de Vilanova, Valencia, Spain (P.C.-S., J.-J.S.-C.)
| | | | - Nuria Reyes-Nuñez
- Respiratory Department (F.C.-R., N.R.-N.), Hospital Universitario de Valme, Seville, Spain
| | - Maria Jose Selma-Ferrer
- Respiratory Department, Hospital Universitario y Politecnico La Fe, Valencia, Spain (M.J.S.-F., C.N.-S., M.A.M.-G.)
| | - Cristina Navarro-Soriano
- Respiratory Department, Hospital Universitario y Politecnico La Fe, Valencia, Spain (M.J.S.-F., C.N.-S., M.A.M.-G.)
| | | | - Juan-José Soler-Cataluña
- From the Respiratory Department, Hospital Arnau de Vilanova, Valencia, Spain (P.C.-S., J.-J.S.-C.)
| | - Pilar Roman-Sanchez
- Internal Medicine Department (P.R.-S.), Hospital General de Requena, Valencia, Spain
| | | | - Miguel A. Martinez-Garcia
- Respiratory Department, Hospital Universitario y Politecnico La Fe, Valencia, Spain (M.J.S.-F., C.N.-S., M.A.M.-G.)
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Lin SH, Branson C, Leung J, Park L, Doshi N, Auerbach SH. Oximetry as an Accurate Tool for Identifying Moderate to Severe Sleep Apnea in Patients With Acute Stroke. J Clin Sleep Med 2018; 14:2065-2073. [PMID: 30518446 DOI: 10.5664/jcsm.7538] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 08/16/2018] [Indexed: 12/19/2022]
Abstract
STUDY OBJECTIVES Sleep-disordered breathing (SDB) is highly prevalent in patients with acute stroke. SDB is often underdiagnosed and associated with neurological deterioration and stroke recurrence. Polysomnography or home sleep apnea testing (HSAT) is typically used as the diagnostic modality; however, it may not be feasible to use regularly in patients with acute stroke. We investigated the predictive performance of pulse oximetry, a simpler alternative, to identify SDB. METHODS The records of 254 patients, who were admitted to Boston Medical Center for acute stroke and underwent HSAT, were retrospectively reviewed. Oxygen desaturation index (ODI) from pulse oximetry channel were compared to respiratory event index (REI) obtained from HSAT devices. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of ODI were calculated, and different ODI cutoff values to predict SDB were proposed. RESULTS ODI had a strong correlation (r = .902) and agreement with REI. ODI was accurate in predicting SDB at different REI thresholds (REI ≥ 5, REI ≥ 15, and REI ≥ 30 events/h) with the area under the curve (AUC) of .965, .974, and .951, respectively. An ODI ≥ 5 events/h rules in the presence of SDB (specificity 91.7%, PPV 96.3%). An ODI ≥ 15 events/h rules in moderate to severe SDB (specificity 96.4%, PPV 95%) and an ODI < 5 events/h rules out moderate to severe SDB (sensitivity 100%, NPV 100%). CONCLUSIONS Nocturnal pulse oximetry has a high diagnostic accuracy in predicting moderate to severe SDB in patients with acute stroke. Oximetry can be a simple modality to rapidly recognize patients with more severe SDB and facilitate the referral to the confirmation sleep study.
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Affiliation(s)
- Shih Hao Lin
- Department of Neurology, Boston Medical Center, Boston, Massachusetts
| | - Chantale Branson
- Department of Neurology, Boston Medical Center, Boston, Massachusetts
| | - Jamie Leung
- Boston University School of Medicine, Boston, Massachusetts
| | - Lisa Park
- Boston University School of Medicine, Boston, Massachusetts
| | - Nirmita Doshi
- Boston University School of Medicine, Boston, Massachusetts
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Gupta A, Shukla G. Obstructive Sleep Apnea and Stroke. J Clin Sleep Med 2018; 14:1819. [PMID: 30353831 PMCID: PMC6175788 DOI: 10.5664/jcsm.7416] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 08/13/2018] [Accepted: 08/13/2018] [Indexed: 11/13/2022]
Affiliation(s)
- Anupama Gupta
- Department of Neurology, All India Institute of Medical Sciences, New Delhi
| | - Garima Shukla
- Department of Neurology, All India Institute of Medical Sciences, New Delhi
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