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Apnea, sleep, obstructive [keywords]
- Effect of CPAP on blood pressure in patients with obstructive sleep apnea and resistant hypertension: the HIPARCO randomized clinical trial. [Journal Article, Research Support, Non-U.S. Gov't]
- JAMA 2013 Dec 11; 310(22):2407-15.
More than 70% of patients with resistant hypertension have obstructive sleep apnea (OSA). However, there is little evidence about the effect of continuous positive airway pressure (CPAP) treatment on blood pressure in patients with resistant hypertension.To assess the effect of CPAP treatment on blood pressure values and nocturnal blood pressure patterns in patients with resistant hypertension and OSA.Open-label, randomized, multicenter clinical trial of parallel groups with blinded end point design conducted in 24 teaching hospitals in Spain involving 194 patients with resistant hypertension and an apnea-hypopnea index (AHI) of 15 or higher. Data were collected from June 2009 to October 2011.CPAP or no therapy while maintaining usual blood pressure control medication.The primary end point was the change in 24-hour mean blood pressure after 12 weeks. Secondary end points included changes in other blood pressure values and changes in nocturnal blood pressure patterns. Both intention-to-treat (ITT) and per-protocol analyses were performed.A total of 194 patients were randomly assigned to receive CPAP (n = 98) or no CPAP (control; n = 96). The mean AHI was 40.4 (SD, 18.9) and an average of 3.8 antihypertensive drugs were taken per patient. Baseline 24-hour mean blood pressure was 103.4 mm Hg; systolic blood pressure (SBP), 144.2 mm Hg; and diastolic blood pressure (DBP), 83 mm Hg. At baseline, 25.8% of patients displayed a dipper pattern (a decrease of at least 10% in the average nighttime blood pressure compared with the average daytime blood pressure). The percentage of patients using CPAP for 4 or more hours per day was 72.4%. When the changes in blood pressure over the study period were compared between groups by ITT, the CPAP group achieved a greater decrease in 24-hour mean blood pressure (3.1 mm Hg [95% CI, 0.6 to 5.6]; P = .02) and 24-hour DBP (3.2 mm Hg [95% CI, 1.0 to 5.4]; P = .005), but not in 24-hour SBP (3.1 mm Hg [95% CI, -0.6 to 6.7]; P = .10) compared with the control group. Moreover, the percentage of patients displaying a nocturnal blood pressure dipper pattern at the 12-week follow-up was greater in the CPAP group than in the control group (35.9% vs 21.6%; adjusted odds ratio [OR], 2.4 [95% CI, 1.2 to 5.1]; P = .02). There was a significant positive correlation between hours of CPAP use and the decrease in 24-hour mean blood pressure (r = 0.29, P = .006), SBP (r = 0.25; P = .02), and DBP (r = 0.30, P = .005).Among patients with OSA and resistant hypertension, CPAP treatment for 12 weeks compared with control resulted in a decrease in 24-hour mean and diastolic blood pressure and an improvement in the nocturnal blood pressure pattern. Further research is warranted to assess longer-term health outcomes.clinicaltrials.gov Identifier: NCT00616265.
- Modified Hyoid Suspension Technique in the Treatment of Multilevel Related Obstructive Sleep Apnea. [JOURNAL ARTICLE]
- Otolaryngol Head Neck Surg 2013 Dec 10.
ObjectiveUsing the Hörmann technique of hyoid suspension in sleep apnea surgery, a steel wire is placed through the thyroid cartilage and slung around the hyoid bone. However, we experienced thyroid cartilage fracture by steel wire traction. A modification is presented to avoid thyroid cartilage fracture.Study DesignCase series with chart review.SettingUniversity hospital.Subjects and MethodsTwenty-seven patients affected by obstructive sleep apnea syndrome underwent Hörmann hyoid suspension. In 2 patients, the steel wire caused a fracture of the thyroid cartilage. The technique was therefore modified in 25 subsequent patients. The wire is threaded through an adaptation titanium miniplate placed on the surface of the thyroid cartilage.ResultsThe apnea-hypopnea index decreased from 43.1 to 10.9/h. Nineteen patients (76%) met the criteria for a successful outcome. No complications related to this modification were noted.ConclusionsThe Hörmann hyoid suspension is a procedure that advances the hyoid bone to expand the airway, and its effectiveness has been proven previously. The modified hyoid suspension presented here promises similar results without the risk of serious complications such as thyroid cartilage fracture.
- Treatment of obstructive sleep apnea with oral appliances. [Journal Article]
- Prog Orthod 2013; 14(1):10.
The purpose of this study was to evaluate the effectiveness of mandibular advancement devices (MADs) for treatment of obstructive sleep apnea syndrome (OSAS) compared with the results obtained with a placebo device in accordance with the following indicators: apnea hypopnea index (AHI) per hour of sleep, apnea index (AI) per hour of sleep, mean oxyhemoglobin saturation, sleep efficiency, and percentage of rapid eye movement (REM) sleep.This is a controlled, prospective longitudinal study with a follow-up time of 10.5 months. Nineteen patients (8 females and 11 males) with mean age 48.6 years (SD 9.6) were selected for the study. The sample was randomized in terms of device use, and the evaluation design was double blind. A total of 57 polysomnography tests were studied (at baseline, after the use of a MAD, and after the use of placebo). The following variables were assessed: AHI, AI, mean oxyhemoglobin saturation, percentage of REM sleep, and sleep efficiency. Wilcoxon and Mann-Whitney tests were used for evaluating data (p < 0.05).Reductions from 16.3 to 11.7 in AHI and from 5.7 to 3.8 in AI were observed after MAD use. During the use of placebo, AHI increased from 16.3 to 19.6, and AI from 5.7 to 7.5. The other indexes showed no statistically significant differences.Treatment with oral appliances, i.e., MADs, can be an effective alternative for mild and medium-to-moderate OSAS, but requires strict monitoring due to differences in individual response to this therapy.
- Salivary markers of oxidative stress in patients with obstructive sleep apnea treated with continuous positive airway pressure. [JOURNAL ARTICLE]
- Sleep Breath 2013 Dec 10.
Obstructive sleep apnea syndrome (OSAS) is characterized by elevated oxidative stress. Measurement of oxidative stress in saliva seems to be promising in long-term treatment monitoring of OSAS patients. In this study, our aim was to investigate whether short-term continuous positive airway pressure (CPAP) treatment would influence oxidative stress in saliva.Patients with diagnosed OSAS (16 women, 28 men) underwent polysomnography during the first night and CPAP treatment during the second night. Saliva samples were taken in the evening and morning on both days. Markers of oxidative stress and antioxidant status were analyzed in saliva.Evening concentrations of the salivary thiobarbituric acid reacting substances (p < 0.001), advanced glycation end-products (p < 0.001), and advanced oxidation protein products (p < 0.01) were significantly lower than morning values during the diagnostic night. However, salivary concentrations of none of the oxidative stress markers were significantly influenced by the CPAP treatment. No changes in salivary antioxidant status after CPAP therapy were found.Salivary markers of oxidative stress and antioxidant status do not change significantly after one night treatment with CPAP. On the contrary, after 1 month with CPAP therapy, reduced markers of oxidative stress were reported. Therefore, the future studies should be focused on finding the optimal sampling frequency to clarify the potential of saliva for the monitoring of OSAS treatment.
- Obesity and Obstructive Sleep Apnea in Patients With Keratoconus in a Turkish Population. [JOURNAL ARTICLE]
- Cornea 2013 Dec 6.
The aim of this study was to compare the frequency of occurrence of obesity and high risk of developing obstructive sleep apnea (OSA) in a keratoconus population with that of a control group.This prospective, case-controlled multicenter study was performed on patients with keratoconus and age- and gender-matched control subjects. One hundred forty-six patients were included in each group, and the Berlin Questionnaire was used for classifying patients as having a high risk or low risk of developing OSA. The patients' demographic and clinical characteristics were compared with the Mann-Whitney U test for continuous variables and with the χ test for categorical variables.The keratoconus (85 male/61 female) and control (79 male/67 female) groups' median ages were 25 (8-65) and 24 (9-60) years, respectively. Of the 146 patients in each group, 11 (7.5%) patients were determined to be at a high risk of developing OSA in the keratoconus group, and 8 (5.5%) patients were determined to be at a high risk of developing OSA in the control group. There was no significant difference between the groups (P = 0.477). The keratoconus and control groups' median body mass index values were found to be within normal ranges of 23.2 and 23.4, respectively.In this study, the mean body mass index value of the keratoconus group was determined to be within normal limits. In a Turkish population, the ratio of a high risk of developing OSA was not found to be significantly different between the keratoconus and control groups.
- Sex differences in forearm vasoconstrictor response to voluntary apnea. [JOURNAL ARTICLE]
- Am J Physiol Heart Circ Physiol 2013 Dec 6.
Clinical evidence indicates that obstructive sleep apnea is more common and more severe in men compared to women. Sex differences in the vasoconstrictor response to hypoxemia-induced sympathetic activation might contribute to this clinical observation. In the current laboratory study, we determined sex differences in the acute physiological responses to maximal voluntary end-expiratory apnea (MVEEA) during wakefulness in healthy young men and women (26 ± 1 yrs) as well as healthy older men and women (64 ± 2 yrs). Mean arterial pressure (MAP), heart rate (HR), brachial artery blood flow velocity (BBFV, Doppler ultrasound) and cutaneous vascular conductance (CVC, laser Doppler flowmetry) were measured and changes in physiological parameters from baseline were compared between groups. The breath hold duration and oxygen saturation nadir were similar between groups. In response to MVEEA, young women had significantly less forearm vasoconstriction compared to young men (ΔBBFV: 2 ± 7 versus -25 ± 6% and ΔCVC: -5 ± 4 versus -31 ± 4 %) whereas ΔMAP (12 ± 2 versus 16 ± 3 mmHg) and ΔHR (4 ± 2 versus 6 ± 3 bpm) were comparable between groups. The attenuated forearm vasoconstriction in young women was not observed in postmenopausal women (ΔBBFV -21 ± 5%). We conclude that young women have blunted forearm vasoconstriction in response to MVEEA compared to young men and this effect is not evident in older postmenopausal women. These data suggest that female sex hormones dampen neurogenic vasoconstriction in response to apnea-induced hypoxemia.
- Obstructive Sleep Apnea and Hypoxemia Are Associated with Advanced Liver Histology in Pediatric Nonalcoholic Fatty Liver Disease. [JOURNAL ARTICLE]
- J Pediatr 2013 Dec 6.
To determine whether obstructive sleep apnea (OSA) and/or nocturnal hypoxemia are associated with the severity of liver injury in patients with pediatric nonalcoholic fatty liver disease (NAFLD).Obese children aged 10-18 years with liver biopsy-proven NAFLD were enrolled. Demographic, clinical, and laboratory data were collected, polysomnography was performed, and liver histology was scored. Subjects were divided into those with OSA/hypoxemia and those without OSA/hypoxemia for analysis.Of 25 subjects with NAFLD, OSA/hypoxemia was present in 15 (60%) (mean age, 12.8 ± 1.9 years; 68% male; 88% Hispanic; mean body mass index z-score, 2.3 ± 0.3). Subjects with and without OSA/hypoxemia had similar levels of serum aminotransferases, serum lipids, and inflammatory and insulin resistance markers. Although there were no differences between groups in the histological severity of steatosis, inflammation, ballooning degeneration, NAFLD activity score, or histological grade, subjects with OSA/hypoxemia had significantly more severe hepatic fibrosis. Moreover, oxygen saturation nadir during polysomnography was related to hepatic fibrosis stage (r = -0.49; P = .01) and aspartate aminotransferase level (r = 0.42; P < .05). Increasing percentage of time with oxygen saturation ≤90% was related to NAFLD inflammation grade (r = 0.44; P = .03), degree of hepatic steatosis (r = -0.50; P = .01), NAFLD activity score (r = 0.42; P = .04), aspartate aminotransferase level (r = 0.56; P = .004), and alanine aminotransferase level (r = 0.44; P = .03).Moderate OSA/hypoxemia is common in pediatric patients with biopsy-proven NAFLD. OSA and the severity/duration of hypoxemia are associated with biochemical and histological measures of NAFLD severity.
- Metabolic Syndrome and Non-Cardiac Vascular Diseases: an Update from Human Studies. [JOURNAL ARTICLE]
- Curr Pharm Des 2013 Dec 5.
The metabolic syndrome (MetS) is characterized by a cluster of risk factors including central obesity, hypertension, dyslipidemia and insulin resistance, The MetS is associated with an increased risk for cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM). Several international organizations have defined MetS using different diagnostic criteria that produced discrepancies in the results of previous studies, thus leading to the latest Joint Interim Societies (JIS) MetS definition. Other risk factors than the diagnostic criteria that have been associated with MetS include lipid abnormalities, uric acid, liver function, prothrombotic factors, cytokines, adipokines, vitamin D, arterial stiffness, polycystic ovary syndrome and obstructive sleep apnea. Apart from CVD and T2DM, MetS has been related to non-cardiac vascular diseases and in particular to stroke, carotid artery disease, peripheral artery disease, chronic kidney disease, atherosclerotic renal artery stenosis and abdominal aortic aneurysms. In this narrative review, the associations of these diseases with MetS and its components will be discussed. These associations may further increase CVD risk in MetS patients, highlighting the importance of treating such high-risk individuals early and "to target". In this context, multifactorial treatment including a statin has been proven beneficial, and thus should be considered, in MetS patients.
- Continuous positive airway pressure treatment improves cardiovascular outcomes in elderly patients with cardiovascular disease and obstructive sleep apnea. [JOURNAL ARTICLE]
- Heart Vessels 2013 Dec 8.
Obstructive sleep apnea (OSA) is associated with the progression of cardiovascular disease (CVD), particularly in the middle-aged population. However, the clinical importance of OSA as a risk for CVD in the elderly population remains controversial. Moreover, evidence for the effectiveness of continuous positive airway pressure (CPAP) treatment for the secondary prevention of CVD in elderly patients is lacking. We assessed whether CPAP treatment improves cardiovascular outcomes in elderly patients with OSA and CVD. In this retrospective cohort study, we enrolled 130 elderly patients aged 65-86 years with moderate to severe OSA (apnea-hypopnea index ≥15/h) and a history of hospitalization due to CVD, who underwent polysomnography between November 2004 and July 2011. Patients were divided into the CPAP group (n = 64) or untreated OSA group (n = 66). The main outcome measures were cardiovascular death and hospitalization due to CVD. During the mean follow-up period of 32.9 ± 23.8 (standard deviation) months, 28 (21.5 %) patients either died or were hospitalized. The Kaplan-Meier curves indicated that event-free survival was significantly lower in the untreated OSA group than in the CPAP group (P < 0.005). A multivariate analysis showed that the risk was significantly increased in the untreated OSA group (hazard ratio 5.13; 95 % confidence interval 1.01-42.0; P < 0.05). Moderate to severe OSA not treated with CPAP was an independent risk factor for relapse of a CVD event, and adequate CPAP treatment improved cardiovascular outcomes in elderly patients.
- Obstructive Sleep Apnea in North American Commercial Drivers. [JOURNAL ARTICLE]
- Ind Health 2013 Dec 9.
The most common medical cause of excessive daytime sleepiness (EDS) is obstructive sleep apnea (OSA). Specifically, among an estimated 14 million US commercial drivers, 17-28% or 2.4 to 3.9 million are expected to have OSA. Based on existing epidemiologic evidence, most of these drivers are undiagnosed and not adequately treated. Untreated OSA increases the risk of vehicular crashes as documented in multiple independent studies and by meta-analysis. Therefore, identifying commercial drivers with OSA and having them effectively treated should decrease crash-related fatalities and injuries. Several strategies are available for screening and identifying drivers with OSA. The simplest and most effective objective strategies use body mass index (BMI) cutoffs for obesity. Functional screens are promising adjuncts to other objective tests. The most effective approach will likely be a combination of a good questionnaire; BMI measures; and a careful physician-obtained history complemented by a functional screen.