Effects of obstructive sleep apnea on the thoracic aorta and the main pulmonary artery: assessment by CT

Sleep apnea predicts cardiovascular death in patients with Marfan syndrome: a cohort study

Background

Surgical replacement of the aortic root is the only intervention that can prevent aortic dissection and cardiovascular death in Marfan syndrome (MFS). However, in some individuals, MFS also causes sleep apnea. If sleep apnea predicts cardiovascular death, a new target for predictive, preventive, and personalized medicine (PPPM) may emerge for those individuals with MFS who have sleep apnea.

Methods

This is an investigator-initiated study with long-term follow-up data of 105 individuals with MFS. All individuals were screened for sleep apnea regardless of symptoms. Cardiovascular death served as a primary endpoint, and aortic events as a secondary outcome.

Results

Sleep apnea with an apnea–hypopnea index (AHI) > 5/h was observed in 21.0% (22/105) with mild sleep apnea in 13% (14/105) and moderate to severe sleep apnea in 7.6% (8/105). After a median follow-up of 7.76 years (interquartile range: 6.84, 8.41), 10% (10/105) had died, with cardiovascular cause of death in 80% (8/10). After adjusting for age and body mass index (BMI), the AHI score emerged as an independent risk factor for cardiovascular death (hazard ratio 1.712, 95% confidence interval [1.061–2.761], p = 0.0276). The secondary outcome of aortic events occurred in 33% (35/105). There was no effect of the AHI score on aortic events after adjusting for age and BMI (hazard ratio 0.965, 95% confidence interval [0.617–1.509]), possibly due to a high number of patients with prior aortic surgery.

Interpretation

Sleep apnea is emerging as an independent predictor of cardiovascular death in MFS. It seems mandatory to screen all individuals with MFS for sleep apnea and to include these individuals, with both MFS and sleep apnea, in further studies to evaluate the impact of preventive measures with regard to cardiovascular death.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13167-022-00291-4.

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

AIM

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

Obstructive sleep apnea in patients with acute aortic dissection

Background

Obstructive sleep apnea (OSA) imposes an afterload burden on the left ventricle and increases the pressure gradient across the aortic wall. Thus, OSA may increase the risk for aortic dissection (AD).

Methods

This study enrolled 40 subjects with acute AD from four institutions; 37 completed the modified Berlin Questionnaire and 31 underwent attended overnight polysomnography. Aortic diameter was measured on a computed tomography scan at seven locations from the sinotubular junction to the diaphragm.

Results

Twenty‐seven subjects had type A dissection; 13 had type B. In those who had polysomnography apnea–hypopnea index (AHI) ranged from 0.7 to 89. Prevalence of OSA (AHI ≥ 5) was 61%. Nocturnal presentation (10 p.m.–7 a.m.) did not differ by presence/absence of OSA. The modified Berlin Questionnaire was not predictive of the presence of OSA. Among type A subjects with polysomnography (n = 23), aortic diameters at all locations were greater in the OSA group though differences were not statistically significant. Summating aortic diameters at the seven locations also yielded a numerically larger mean value in the OSA group versus the non‐OSA group.

Conclusions

In this sample of patients with acute dissection, OSA was prevalent but was not associated with a nocturnal presentation. The presence of underlying OSA may be associated with larger aortic diameters at the time of dissection compared to patients without OSA. Though differences did not meet statistical significance the current series is limited by small numbers.