Effects of CPAP on "vascular" risk factors in patients with obstructive sleep apnea and arterial hypertension

Background

The aim of this study was to assess the effects of continuous positive airway pressure (CPAP) on arterial stiffness, central blood pressure, and reflected pulse wave characteristics in patients with severe obstructive sleep apnea (OSA) and stage 2–3 arterial hypertension.

Methods

Forty-four patients with hypertension and severe OSA (apnea/hypopnea index > 30) received stepped dose titration of antihypertensive treatment, consisting of valsartan 160 mg + amlodipine 5–10 mg + hydrochlorothiazide 25 mg. CPAP therapy was added after 3 weeks of continuous antihypertensive treatment with BP < 140/90 mmHg or after adjusting triple treatment in patients with resistant arterial hypertension. The patients were randomized to effective CPAP (4–15 mm H₂O) or placebo CPAP (pressure 4 mm H₂O) for three weeks, then crossed over to the alternative treatment in a single-blind manner. Office blood pressure (BP), ambulatory BP monitoring, ambulatory arterial stiffness index (AASI), aortic BP, carotid-femoral pulse wave velocity (cfPWV), and systolic wave augmentation index were measured using a Sphygmocor® device at baseline, after antihypertensive treatment, placebo CPAP, and effective CPAP.

Results

Baseline cfPWV was above the normal range in 94% of patients. After reaching target BP, the cfPWV decreased by 1.9 ± 1.0 msec (P = 0.007). Effective CPAP achieved a further cfPWV reduction of 0.7 msec (P = 0.03). Increased arterial stiffness (pulse wave velocity > 12 msec) persisted in 35% of patients on antihypertensive treatment and effective CPAP, in 56% of patients on antihypertensive treatment alone, and in 53% of patients on placebo CPAP. Only the combination of antihypertensive treatment with effective CPAP achieved a significant reduction in augmentation index and AASI, along with a further reduction in aortic and brachial BP.

Conclusion

Effective CPAP for 3 weeks resulted in a significant additional decrease in office BP, ambulatory BP monitoring, central BP, and augmentation index, together with an improvement in arterial stiffness parameters, ie, cfPWV and AASI, in a group of hypertensive patients with OSA.

[Influence of modifiable cardiovascular risk factors on antihypertensive therapy efficiency escape]

AIM

To evaluate the influence of cardiovascular risk factors on antihypertensive therapy (AHT) efficiency escape (EE).

SUBJECTS AND METHODS

Data on 59 patients with grades 1-3 hypertension (Stages I-II) were analyzed. During chosen AHT, 24-hour blood pressure monitoring was done at baseline, 1 and 3 months after beginning the observation to identify/rule out the AHT EE phenomenon.

RESULTS

The AHT EE group (Group 1) as compared with the group that needed no therapy correction within 3 months (Group 2) was observed to have the following: elevated fasting blood glucose levels (FBGL) (5.8±0.8 vs 5.3±0.7 mmol/l; p=0.008) and higher impaired glucose tolerance (IGT) rates (8 (27.6%) vs 4 (13.3%) cases (p=0.03)); a more number of smoking patients (8 (27.6%) vs 3 (10%) cases; p=0.02); a larger number of patients with a compromised family history of cardiovascular diseases (17 (58.6%) vs 11 (36%); p=0.02). Furthermore, in Group 1 baseline average systolic blood pressure during 24 hours (SBP-24) proved to be higher than that in Group 2 (127.4±4.2 vs 122.4±6.8 mm Hg; p=0.002). Odds ratio (OR) for developing the EE phenomenon increased by 60% with a rise of 0.5 mmol in FBGL (OR, 1.60; 95% confidence interval (CI), 1.06 to 2.4; p=0.02) and by 18% with an increase of 1 mm Hg in baseline SBP-24 (OR, 1.18; 95% CI, 1.05 to 1.33; p=0.004). Multivariate analysis indicated that the independent predictors of AHT EE were a compromised family history (OR, 3.7; 95% CI, 1.1 to 12.1; p=0.03) and IGT (OR, 4.1; 95% CI, 1.02 to 16.4; p=0.04).

CONCLUSION

AHT EE was influenced by FBGL, IGT, smoking, a compromised family history, and baseline SBP-24 level.

The effectiveness of combination antihypertensive therapy in patients with arterial hypertension and additional risk factors: obesity and obstructive sleep apnea syndrome

AIM

To study the effectiveness of a fixed combination of perindopril and amlodipine, with the subsequent addition of indapamide-retard in male patients with arterial hypertension (AH), obesity and severe sleep apnea (OSAS).

MATERIALS AND METHODS

The study included 43 male patients in whom antihypertensive therapy titration was performed to achieve target blood pressure values with a fixed combination of calcium antagonist amlodipine (10 mg) and an angiotensin-converting inhibitor perindopril (5-10 mg) and indapamide-retard. At baseline and after 4-6 weeks, the effectiveness of antihypertensive therapy was monitored according to clinical measurements and ambulatory blood pressure monitoring (ABPM). An assessment of the carotid-femoral pulse wave velocity (cfPWV), aortic PWV (aoPWV), and ankle-brachial PWV (abPWV) was performed.

RESULTS

Target blood pressure values (according to clinical blood pressure, 24-hour blood pressure monitoring) during therapy with amlodipine 10 mg and perindopril 10 mg reached 65% of patients and another 30% reached target blood pressure when adding indapamide-retard 1.5 mg, that is - 95% of all patients included in the study. Upon reaching the target blood pressure values, a significant decrease in cfPWV, aoPWV and abPWV was observed.

CONCLUSION

The fixed combination of perindopril arginine and amplodipine, with the addition of indapamide retard in male patients with hypertension 1st degree in the presence of obesity and severe OSAS allows to reach effective control of blood pressure and improve the elastic properties of large arteries, which can lead to a favorable organoprotective effect in this category of patients.

[Atrial fibrillation and prolonged nocturnal cardiac arrests in a patient with obstructive sleep apnea syndrome. Successful correction of disorders by CPAP therapy]

The case history of a 46-year-old patient with obstructive sleep apnea syndrome was analyzed. The examination revealed fourth-degree obesity, prior myocardial infarction, persistent atrial fibrillation with nocturnal asystoles lasting as long as 14.3 sec. During selected drug therapy and regular application of secondary ventilation (continuous positive airway pressure (CPAP) therapy) used to correct breathing problems, there was a reduction in the signs of circulatory deficiency, cessation of cardiac pauses, and recovery of sinus rhythm. The therapeutic effect persisted during a 24-month follow-up.

[Adherence and efficacy of long-term PAP therapy in patients with sleep-related breathing disorders associated with cardiac conduction disorders]

AIM

To study the effectiveness of prolonged use of PAP therapy (positive airway pressure therapy) in eliminating sleep respiratory disorders and associated cardiac conduction disturbances.

MATERIALS AND METHODS

We included 21 patients who were examined at the Myasnikov Institute of Clinical Cardiology, National Medical Research Center of Cardiology, regarding cardiac rhythm and conduction disturbances, as well as obstructive sleep apnea and who have been on PAP therapy for more than 12 months. The average age was 66.5 [63.5; 73.2] years, body mass index 33.0 [30.2; 38.5] kg/m2, apnea-hypopnea index 65.0 [59.0; 86.3]/h. At the time of analysis, 15 patients continued to use PAP therapy (mean time of use: 6.0 years [4.7; 9.2]) and 6 patients refused long-term use of PAP therapy, mean time to use PAP therapy until failure amounted to 2.82.1 years.

RESULTS

PAP therapy lead to a persistent decrease in apnea-hypopnea index of 63.6/h to 3.7/h was (p=0.0002). 86% of patients met the criteria for adherence to PAP therapy (use 4 hours/night, more than 70% of nights). Initially, before the use of PAP therapy, all cardiac conduction disorders were during sleep and exceeded 3 seconds, with fluctuations from 3.1 to 10.6 seconds. PAP therapy appeared to be effective in all patients: no asystoles, duration of more than 3 seconds, were detected.

CONCLUSION

In obstructive sleep apnea patients with concomitant nighttime cardiac conduction disturbances, the long-term use of PAP therapy is effective and with good adherence.

[A clinical case of hemangioma of the face and tongue concurrent with severe obstructive sleep apnea syndrome complicated by cardiac arrhythmias and conduction disturbances]

The paper describes a clinical case of a female patient with severe obstructive sleep apnea syndrome in the presence of congenital hemangioma of the face, soft palate, and tongue concurrent with paroxysmal atrial fibrillation and atrial flutter, paroxysmal supraventricular tachycardia, and sinoatrial block (maximally up to 3.9 sec). Continuous positive airway pressure therapy could reduce the number of paroxysms of atrial fibrillation and atrial flutter, supraventricular tachycardia and eliminate sinoatrial block.

Interrelation of erectile dysfunction with obesity in patients with arterial hypertension

AIM

To study the relationship between the severity of erectile dysfunction and the anthropometric parameters of obesity in patients with arterial hypertension.

MATERIALS AND METHODS

The study included 71 patients with different severity of erectile dysfunction, overweight and grade 1obesity and arterial hypertension. The anthropometric parameters were analyzed, the degree and characteristics of obesity were assessed according to data of multispiral computed tomography (MSCT), a preliminary assessment of erectile function was performed using the IIEF-5 questionnaire. Later the data of the questionnaire was compared with the in-depth urological study: the collection of anamnesis, examination and conduction of the pharmacodopplerography of the penis vessels.

RESULTS

Comparative analysis revealed statistically significant links between anthropometric data and the degree of abdominal obesity based on MSCT results (p&lt;0.005), anthropometric indicators of obesity with parameters of penile arterial blood flow, as well as severity of erectile dysfunction by degree of erection and dopplerography with an estimation of the rate of penile blood flow (p&lt;0.05). In addition, a statistically significant negative relationship between the quality of penile blood flow and the degree of arterial hypertension was revealed (p=0.02). As a result of multifactorial linear regression, it is shown that with an increased the ratio of the waist circumference to the hip circumference and a higher level of systolic blood pressure, the condition of penile arterial blood flow worsens, namely, the peak systolic velocity (PSV) decreases (β=-0.377, p=0.05; β=-0.478, p=0.02, respectively). In a comparative analysis of the subjective evaluation of erectile function according to the data of the IIEF-5 questionnaire, we showed no statistically significant association with the results of an objective examination (p=0.07).There were also no statistically significant links between objective data of erectile function and obesity parameters in MSCT.

CONCLUSION

The combination of overweight or obesity with arterial hypertension gives ground to suspect the presence of different severity of erectile dysfunction.

Clinical observation of a patient with arterial hypertension and obstructive sleep apnea syndrome

The clinical observation of a postmenopausal patient with the syndrome of obstructive sleep apnea in the outpatient health care stage.

[Obstructive sleep apnea syndrome and cardiovascular risk factors in the antihypertensive therapy "escape" phenomenon]

AIM

To assess the role of obstructive sleep apnea and other cardiovascular (CV) risk factors in the development of the antihypertensive therapy (AHT) efficacy "escape" phenomenon in patients with arterial hypertension (AH).

MATERIALS AND METHODS

The data of 75 patients with AH stage I-II, grades 1-3 were proceeded. All patients included in the study underwent night respiratory monitoring. After AHT prescription, blood pressure (BP) was monitored by three measurement methods (office, daily monitoring and self-control of blood pressure) - initially, in 1, 3 and 6 months after the inclusion - in order to confirm the initial therapy efficacy and to identify or exclude the "escape" phenomenon.

RESULTS

In 36.0% of patients, the "escape" phenomenon was diagnosed in 1 or 3 months of observation. When comparing the group with the "escape" phenomenon, an initially higher level of systolic BP was revealed according to office measurements, 24-hour monitoring and self-control BP monitoring (134.0±4.7 mmHg vs 126.0±8.5 mmHg; 129.0±2.3 mmHg vs 121.0±7.7 mmHg; 131.0±8.2 mmHg vs 121.5±6.2 mmHg resp.; р<0,05). There were no differences in sleep apnea and CV risk factors between the groups. However in patients with a minimal SpO₂≤85% during sleep, there were a higher levels of office systolic BP both before the AHT prescription, and during its use (157.6±10.4 mmHg vs 152.4±8.1 mmHg resp., р<0,05; 132.0±6.8 vs 127.1±8.9 mmHg resp.; р<0,05), and mean 24-hour systolic BP (125.7±5.9 vs 121.6±8.2 mmHg resp.; р<0,05) - compared with patients with a minimum SpO₂>85%.

CONCLUSION

The higher BP level in patients with lover nocturnal hypoxemia does not allow us to exclude the delayed negative impact of obstructive sleep apnea, especially severe, on the BP profile in case of initially successful AH control.

[Clinical profile of patients with obstructive sleep apnea syndrome in a cardiology hospital]

RELEVANCE

Obstructive sleep apnea syndrome (OSAS) is an important medical and social problem due to its high prevalence and impact on quality of life. The relationship between OSAS and cardiovascular pathology has been proven by many studies, which confirms the necessity for early diagnosis of OSAS and its treatment for the prevention of fatal and non-fatal events.

AIM

to study epidemiological and clinical profile of the patients referred by a cardiologist to a specialized sleep laboratory to verify the diagnosis of OSAS.

MATERIALS AND METHODS

Object of study 527 patients aged 56.912.5 years who were hospitalized to the Myasnikov Clinical Cardiology Research Institute from 20162018 and had OSAS risk factors. Initially, complaints, medical history, anthropometric data were collected. As a screening survey, questionnaires were conducted using questionnaire scales. Verification of the diagnosis of OSAS and determination of the severity was carried out by cardiorespiratory or respiratory monitoring. Subsequently, 4 groups were formed depending on the presence and severity of OSAS.

RESULTS

The prevalence of OSAS among patients in a cardiology hospital referred to a verification study was 88.6%. A comparative analysis of the groups revealed a progressive increase in the values of anthropometric indicators with increasing severity of OSAS. No differences were found between the groups by gender and daytime sleepiness on the Karolinska Sleepiness Scale. The average score on the Epworth sleepiness scale was statistically significantly lower only in the group of patients without OSAS when compared with the group with a severe degree of OSAS, and is comparable with the scores in the groups of mild and moderate degrees of OSAS. In a multivariate model of logistic regression, independent predictors of OSAS were identified as: age over 45 years, indications of loud intermittent snoring, frequent nightly urination, overweight or obesity. According to the results of assessing the incidence of various cardiovascular diseases in patients referred to the sleep laboratory, no significant differences were detected. At the same time, a significant difference was found in the frequency of obesity in patients with severe OSAS compared with other groups, as well as the frequency of type 2 diabetes mellitus or impaired glucose tolerance when compared with groups without OSAS, and with mild OSAS. In one-factor logistic regression models, it was found that the likelihood of having a severe degree of OSAS increases with increasing both comorbidity and age.

CONCLUSIONS

High prevalence of OSAS in patients of a cardiological hospital, referred to a sleep laboratory for verification study, was confirmed. Considering the data that early diagnosis and treatment of OSAS can affect the course of both nosologies, the quality of life and prognosis of these patients, it is advisable to routinely screen and verify the diagnosis of OSAS in patients with cardiovascular diseases.