Sleep Apnea, Obstructive

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Original Article

Association between Arterial Hypertension and Laboratory Markers, Body Composition, Obstructive Sleep Apnea and Autonomic Parameters in Obese Patients

Clarcson Plácido Conceição Santos et al. Laura Souza Lagares Sarah Rafaela Mascarenhas Santos Mariana Sousa de Pina Silva … Rodrigo Colares de Macedo Luiz Alberto Bastos de Almeida Eric Simas Bomfim

Abstract

Background

Systemic arterial hypertension (SAH) is a multifactorial disease, highly prevalent and associated with health risks.

Objective

The purpose of this study was to investigate the association between SAH and laboratory, anthropometric, heart rate variability (HRV), and obstructive sleep apnea markers and, secondarily, to analyze the sensitivity and specificity of the variables that are independent factors in the association.

Methods

Cross-sectional study with 95 obese patients treated at an obesity referral clinic in Salvador, BA, Brazil. SAH data were obtained from electronic medical records. The sample was stratified in the Normotensive Group (NG) and the Hypertensive Group (HG), and laboratory markers, body composition, polysomnography, and HRV were measured to evaluate the association of SAH with the predictor variables. For the analysis, p<0.05 was adopted.

Results

The average age of the NG was 36.3 ± 10.1 and HG 40.4 ± 10.6 years; 73.7% were women in the NG and 57.9% in HG; 82.4% in HG had insulin resistance. In the multivarious logistics regression model with adjustments in age, sex, height, and oxyhemoglobin saturation, SAH was inversely associated with fasting plasma glucose mg/dL (odds ratio [OR] = 0.96; 95% confidence interval [CI] = 0.92-0.99) and visceral fat area (VFA) cm²(OR = 0.98; 95% CI = 0.97-0.99). The area under the VFA curve was 0.728; CI 95% (0.620-0.836); fasting plasma glucose 0.693;CI 95% (0.582-0.804).

Conclusions

Lower VFA and fasting plasma glucose concentrations were inversely associated with SAH. In addition, fasting plasma glucose and VFA showed a high sensitivity for SAH screening.

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Original Article

Visceral Obesity and High Systolic Blood Pressure as the Substrate of Endothelial Dysfunction in Obese Adolescents

Maria Fernanda Hussid et al. Felipe Xerez Cepeda Camila P. Jordão Rafaela R. P. Lopes-Vicente … Leslie Virmondes Keyla Y. Katayama Ezequiel F. de Oliveira Luis V. F. Oliveira Fernanda Marciano Consolim-Colombo Ivani Credidio Trombetta

Abstract

Background:

Obesity affects adolescence and may lead to metabolic syndrome (MetS) and endothelial dysfunction, an early marker of cardiovascular risk. Albeit obesity is strongly associated with obstructive sleep apnea (OSA), it is not clear the role of OSA in endothelial function in adolescents with obesity.

Objective:

To investigate whether obesity during adolescence leads to MetS and/or OSA; and causes endothelial dysfunction. In addition, we studied the possible association of MetS risk factors and apnea hypopnea index (AHI) with endothelial dysfunction.

Methods:

We studied 20 sedentary obese adolescents (OA; 14.2±1.6 years, 100.9±20.3kg), and 10 normal-weight adolescents (NWA, 15.2±1.2 years, 54.4±5.3kg) paired for sex. We assessed MetS risk factors (International Diabetes Federation criteria), vascular function (Flow-Mediated Dilation, FMD), functional capacity (VO²peak) and the presence of OSA (AHI>1event/h, by polysomnography). We considered statistically significant a P<0.05.

Results:

OA presented higher waist (WC), body fat, triglycerides, systolic (SBP) and diastolic blood pressure (DBP), LDL-c and lower HDL-c and VO²peak than NWA. MetS was presented in the 35% of OA, whereas OSA was present in 86.6% of OA and 50% of EA. There was no difference between groups in the AHI. The OA had lower FMD than NWA (6.17±2.72 vs. 9.37±2.20%, p=0.005). There was an association between FMD and WC (R=-0.506, p=0.008) and FMD and SBP (R=-0.493, p=0.006).

Conclusion:

In adolescents, obesity was associates with MetS and caused endothelial dysfunction. Increased WC and SBP could be involved in this alteration. OSA was observed in most adolescents, regardless of obesity. (Arq Bras Cardiol. 2021; 116(4):795-803)

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Case Report

Very Long Apneas during Prone Position in a Lean Patient with Coronary Artery Disease: Implications for the Cardiovascular Risk

Sofia Fontanello Furlan et al. Viktor Sinkunas Pedro Rodrigues Genta Geraldo Lorenzi Filho Luciano F. Drager

Introduction

Obstructive sleep apnea (OSA) is a common condition characterized by recurrent upper airway obstructions during sleep, promoting intermittent hypoxia and sleep fragmentation. Traditional risk factors for OSA include male gender and obesity. Overall, patients with severe OSA presented longer events and more severe hypoxemia. Supine sleep is consistently associated with more severe OSA rates in adults. However, the relationship between OSA indices and prone position is inconsistent. Here, we reported a very peculiar presentation of OSA characterized by very long respiratory events in a prone position in a lean female patient with a history of high blood pressure, diabetes mellitus, chronic kidney disease under dialysis therapy and a recent diagnosis of coronary artery disease (CAD).

[…]

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Editorial

Obstructive Sleep Apnea: A Marker of Cardiac Remodeling in Patients with Chronic Chagas Disease

Reinaldo B. Bestetti

Chronic Chagas disease (CCD) continues to be a major scourge for people living in South America and an emergent medical problem outside the American Continent because of world globalization. Chronic Chagas heart disease (CCHD) affects about 30% of patients with CCD, appearing 20-30 years after infection with Trypanosoma cruzi. Prognosis of CCD patients is relentless, with a 5-year mortality approaching 35%. CCHD patients have an outcome even worse, particularly those with ventricular and atrial remodeling, which manifests by chronic systolic heart failure and atrial fibrillation.^,

It is, therefore, important to recognize predictors of ventricular and atrial remodeling in patients with CCHD to offer the proper available treatment for patients with this condition. Systolic blood pressure, male sex, and New York Heart Association Functional Class appear to predict ventricular remodeling in patients with CCD. Conversely, as far as I know, predictors of atrial remodeling have not yet been established for patients with this condition.

[…]

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Original Article

Obstructive Sleep Apnea is Common and Associated with Heart Remodeling in Patients with Chagas Disease

Carolina de Araújo Medeiros et al. Isaac Vieira Secundo Carlos Antônio da Mota Silveira José Maria del Castilho … Afonso Luiz Tavares de Albuquerque Sílvia Marinho Martins Wilson de Oliveira Júnior Geraldo Lorenzi-Filho Luciano F. Drager Rodrigo Pinto Pedrosa

Abstract

Background:

Chagas Disease (CD) is an important cause of morbimortality due to heart failure and malignant arrhythmias worldwide, especially in Latin America.

Objective:

To investigate the association of obstructive sleep apnea (OSA) with heart remodeling and cardiac arrhythmias in patients CD.

Methods:

Consecutive patients with CD, aged between 30 to 65 years old were enrolled. Participants underwent clinical evaluation, sleep study, 24-hour Holter monitoring, echocardiogram and ambulatory blood pressure monitoring.

Results:

We evaluated 135 patients [age: 56 (45-62) years; 30% men; BMI: 26 ± 4 kg/m², Chagas cardiomyopathy: 70%]. Moderate to severe OSA (apnea-hypopnea index, AHI, ≥ 15 events/h) was present in 21% of the patients. OSA was not associated with arrhythmias in this population. As compared to patients with mild or no OSA, patients with moderate to severe OSA had higher frequency of hypertension (79% vs. 72% vs. 44%, p < 0.01) higher nocturnal systolic blood pressure: 119 ± 17 vs. 113 ± 13 vs. 110 ± 11 mmHg, p = 0.01; larger left atrial diameter [37 (33-42) vs. 35 (33-39) vs. 33 (30-36) mm, p < 0.01]; and a greater proportion of left ventricular dysfunction [LVEF < 50% (39% vs. 28% vs. 11%), p < 0.01], respectively. Predictor of left atrial dimension was Log₁₀ (AHI) (b = 3.86, 95% CI: 1.91 to 5.81; p 15 events/h (OR = 3.61, 95% CI: 1.31 – 9.98; p = 0.01), systolic blood pressure (OR = 1.06, 95% CI: 1.02 – 1.10; p < 0.01) and male gender (OR = 3.24, 95% CI: 1.31 – 8.01; p = 0.01).

Conclusions:

OSA is independently associated with atrial and ventricular remodeling in patients with CD.

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Original Article

Twenty-four hour Blood Pressure in Obese Patients with Moderate-to-Severe Obstructive Sleep Apnea

Claudia M. Correa et al. Ronaldo A. Gismondi Ana Rosa Cunha Mario F. Neves Wille Oigman

Abstract

Background:

Obesity, systemic arterial hypertension (SAH) and obstructive sleep apnea (OSA) are closely related. Up to 70% of patients with OSA may be asymptomatic, and there is evidence that these patients have cardiovascular disease, especially nocturnal SAH.

Objectives:

The aim of this study was to evaluate 24-hour blood pressure circadian variation in asymptomatic, obese individuals with moderate-to-severe OSA and compare it with that in individuals with mild OSA or without OSA.

Methods:

Eighty-six obese subjects aged between 30 and 55 years (BMI 30-39 kg/m²), with casual blood pressure < 140/90 mmHg and without comorbidities were recruited. Eighty-one patients underwent clinical and anthropometric assessment, ambulatory blood pressure monitoring (ABPM), and Watch-PAT. Participants were divided into two groups, based on the apnea-hypopnea index (AHI): group 1, with AHI < 15 events/hour, and group 2 with AHI ≥ 15 events/hour.

Results:

Compared with group 1, group 2 had higher neck circumference and waist-hip circumference (40.5 ± 3.2 cm vs. 38.0 ± 3.7 cm, p = 0.002, and 0.94 ± 0.05 vs. 0.89 ± 0.05, p = 0.001, respectively), higher systolic and diastolic blood pressure measured by the 24-h ABPM (122 ± 6 vs 118 ± 8 mmHg, p = 0.014, and 78 ± 6 vs 73 ± 7 mmHg, p = 0.008, respectively), and higher nocturnal diastolic pressure load (44,6 ± 25,9% vs 31,3 ± 27,3%, p = 0,041). Moreover, there was a positive correlation between nocturnal diastolic blood pressure and AHI (r = 0.43, p < 0.05).

Conclusions:

Asymptomatic obese subjects with moderate-to-severe OSA have higher systolic and diastolic blood pressure at 24 hours compared with those with absent / mild OSA, despite normal casual blood pressure between the groups. These results indicate that ABPM may be useful in the evaluation of asymptomatic obese patients with moderate-to-severe OSA.

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Review Article

Association between Obstructive Sleep Apnea and Myocardial Infarction: A Systematic Review

Fernanda Porto et al. Yuri Saho Sakamoto Cristina Salles

Abstract

Obstructive sleep apnea (OSA) has been associated to cardiovascular risk factors. However, the association between OSA and cardiovascular disease is still controversial. The objective of the present study was to verify the association between OSA and myocardial infarction (MI). This is a systematic review of the literature performed through electronic data sources MEDLINE/PubMed, PubMed Central, Web of Science and BVS –Biblioteca Virtual em Saúde (Virtual Health Library). The descriptors used were: ‘obstructive sleep apnea’ AND ‘polysomnography’ AND ‘myocardial infarction’ AND ‘adults NOT ‘treatment.’ The present work analysed three prospective studies, selected from 142 articles. The studies followed a total sample of 5,067 OSA patients, mostly composed by male participants. All patients underwent night polysomnography, and all studies found an association between OSA and fatal and non-fatal cardiovascular outcomes. Thus, we were able to observe that 644 (12.7%) of the 5,067 patients suffered MI or stroke, or required a revascularization procedure, and 25.6% of these cardiovascular events were fatal. MI was responsible for 29.5% of all 644 analysed outcomes. There is an association between OSA and MI, in male patients, and apnea and hypopnea index (AHI) are the most reliable markers.

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Original Article

Impact of High Risk for Obstructive Sleep Apnea on Survival after Acute Coronary Syndrome: Insights from the ERICO Registry

Flavia C Maia et al. Alessandra C. Goulart Luciano F. Drager Henrique L. Staniak … Itamar de Souza Santos Paulo Andrade Lotufo Isabela M. Bensenor

Abstract

Background:

Obstructive sleep apnea (OSA) is a very often clinical condition that can be associated with high mortality risk, particularly in coronary heart disease (CHD). The diagnosis of OSA is not always accessible via the gold-standard method polysomnography.

Objective:

To evaluate long-term influence of the high risk for OSA on fatal and non-fatal outcomes after acute coronary syndrome (ACS) in the Acute Coronary Syndrome Registry Strategy (ERICO) Study using the Berlin questionnaire as a surrogate.

Methods:

Berlin questionnaire, a screening questionnaire for OSA, was applied in 639 cases of ACS 30 days after the index event. Cox regression proportional-hazards model was used to calculate the hazard ratio (HR) of all-cause, cardiovascular and CHD (myocardial infarction) mortality, as well as, the combined endpoint of fatal or recurrent non-fatal CHD.

Results:

The high-risk group for OSA had higher frequencies of previous personal/family history of CHD and diabetes, in addition to a poorer event-free survival, as compared to the low-risk group (p-log-rank=0.03). The HR for fatal or recurrent non-fatal CHD was 4.26 (95% confidence interval, 1.18 – 15.36) in patients at high risk for OSA compared to those at low risk for OSA after a 2.6-year mean follow-up.

Conclusions:

Using Berlin questionnaire, we were able to identify high risk for OSA as an independent predictor of non-fatal reinfarction or CHD mortality in post-ACS individuals in a long-term follow-up.

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Original Article

Prevalence of Risk for Obstructive Sleep Apnea Syndrome and Association With Risk Factors in Primary Care

Kenia Vieira da Silva et al. Maria Luiza Garcia Rosa Antônio José Lagoeiro Jorge Adson Renato Leite … Dayse Mary Silva Correia Davi de Sá Silva Diego Bragatto Cetto Andreia da Paz Brum Pedro Silveira Netto Gustavo Domingos Rodrigues

Abstract

Background:

Obstructive sleep apnea syndrome (OSAS) is a chronic, progressive disease with high morbidity and mortality. It is underdiagnosed, especially among women.

Objective:

To study the prevalence of high risk for OSAS globally and for the Berlin Questionnaire (BQ) categories, and to evaluate the reliability of the BQ use in the population studied.

Methods:

Observational, cross-sectional study with individuals from the Niterói Family Doctor Program, randomly selected, aged between 45 and 99 years. The visits occurred between August/2011 and December/2012. Variables associated with each BQ category and with high risk for OSAS (global) were included in logistic regression models (p < 0.05).

Results:

Of the total (616), 403 individuals (65.4%) reported snoring. The prevalence of high risk for OSA was 42.4%, being 49.7% for category I, 10.2% for category II and 77.6% for category III.

Conclusion:

BQ showed an acceptable reliability after excluding the questions Has anyone noticed that you stop breathing during your sleep? and Have you ever dozed off or fallen asleep while driving?. This should be tested in further studies with samples mostly comprised of women and low educational level individuals. Given the burden of OSAS-related diseases and risks, studies should be conducted to validate new tools and to adapt BQ to better screen OSAS.

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Original Article

Sleep Apnea and Nocturnal Cardiac Arrhythmia: A Populational Study

Fatima Dumas Cintra et al. Renata Pimentel Leite Luciana Julio Storti Lia Azeredo Bittencourt … Dalva Poyares Laura de Siqueira Castro Sergio Tufik Angelo de Paola

Background:

The mechanisms associated with the cardiovascular consequences of obstructive sleep apnea include abrupt changes in autonomic tone, which can trigger cardiac arrhythmias. The authors hypothesized that nocturnal cardiac arrhythmia occurs more frequently in patients with obstructive sleep apnea.

Objective:

To analyze the relationship between obstructive sleep apnea and abnormal heart rhythm during sleep in a population sample.

Methods:

Cross-sectional study with 1,101 volunteers, who form a representative sample of the city of São Paulo. The overnight polysomnography was performed using an EMBLA® S7000 digital system during the regular sleep schedule of the individual. The electrocardiogram channel was extracted, duplicated, and then analyzed using a Holter (Cardio Smart®) system.

Results:

A total of 767 participants (461 men) with a mean age of 42.00 ± 0.53 years, were included in the analysis. At least one type of nocturnal cardiac rhythm disturbance (atrial/ventricular arrhythmia or beat) was observed in 62.7% of the sample. The occurrence of nocturnal cardiac arrhythmias was more frequent with increased disease severity. Rhythm disturbance was observed in 53.3% of the sample without breathing sleep disorders, whereas 92.3% of patients with severe obstructive sleep apnea showed cardiac arrhythmia. Isolated atrial and ventricular ectopy was more frequent in patients with moderate/severe obstructive sleep apnea when compared to controls (p < 0.001). After controlling for potential confounding factors, age, sex and apnea-hypopnea index were associated with nocturnal cardiac arrhythmia.

Conclusion:

Nocturnal cardiac arrhythmia occurs more frequently in patients with obstructive sleep apnea and the prevalence increases with disease severity. Age, sex, and the Apnea-hypopnea index were predictors of arrhythmia in this sample.

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Artigo Original

Cardiovascular profile in patients with obstructive sleep apnea

Fátima Dumas Cintra et al. Sergio Tufik Angelo de Paola Márcia C. Feres … Luciane Melo-Fujita Wercules Oliveira Camila Rizzi Dalva Poyares

BACKGROUND: Obstructive Sleep Apnea (OSA) is a risk factor for several cardiovascular conditions including increased cardiovascular mortality. It is therefore essential to know the major cardiovascular effects of sleep-disordered breathing during a clinical evaluation. OBJECTIVE: To analyze the cardiovascular characteristics of patients with OSA. METHODS: Patients underwent baseline polysomnography and were consecutively selected from the database of the Sleep Institute between March 2007 and March 2009. All patients were instructed to attend the clinic for blood collection, physical examination, 12-lead electrocardiogram, spirometry, cardiopulmonary exercise testing on a treadmill and transthoracic echocardiography. The study was approved by the Research Ethics Committee and recorded at http://clinicaltrials.gov/ under number: NCT00768625. RESULTS: We analyzed 261 patients and 108 controls. The main characteristics of patients with OSA were: obesity, hypertension, low plasma levels of high density lipoprotein (HDL) and increased left atrial diameter compared with controls (3.75 ± 0.42; 3.61 ± 0.41, p = 0.001), respectively. These associated characteristics correspond to a 16.6 increase in the likelihood of OSA regardless of reporting any symptoms of this disorder, such as sleepiness or snoring. CONCLUSION: In the sample studied, the mostly found cardiovascular profile of patients with OSA was: obesity, hypertension, low plasma levels of HDL and left atrial diameter increased.

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Atualização

Recent advances of the impact of obstructive sleep apnea on systemic hypertension

Rodrigo P. Pedrosa et al. Eduardo M. Krieger Geraldo Lorenzi-Filho Luciano F. Drager

Obstructive sleep apnea (OSA) is a common clinical condition in the general population, especially among patients with cardiovascular diseases. More than just a local phenomenon of upper respiratory tract obstruction, OSA leads to systemic consequences that may include intermittent hypoxia, sudden reduction of the intrathoracic pressure, and the occurrence of micro-awakenings with sleep fragmentation. In the past decades, innumerous evidences have consistently pointed to OSA as an important factor related to the presence of cardiovascular diseases. In particular, the relationship between OSA and systemic hypertension (SH) is the one supported by the largest body of evidence. Currently, there are data suggesting that OSA is an important secondary cause of SH. More importantly, OSA is independently associated with poorer blood pressure control, changes in sleep dip, and presence of target-organ damage such as left ventricular hypertrophy and microalbuminuria. Randomized studies suggest that the management of OSA, especially with continuous positive airway pressure (CPAP) – which is considered the standard treatment for OSA – promotes a significant 24-hour blood pressure reduction, and this effect is more significant in the subgroup of patients with uncontrolled SH and drug-resistant SH. Despite all those evidences, OSA has still been underdiagnosed. The objective of this review is to discuss the recent advances in the pathophysiological mechanisms, clinical presentation, and treatment of OSA, as well as the benefits this treatment can bring on blood pressure.

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Artigo Original

Suspicion of Obstructive Sleep Apnea by Berlin Questionnaire predicts events in patients with Acute Coronary Syndrome

Eryca Vanessa S. de Jesus et al. Euvaldo B. Dias-Filho Bethania de M. Mota Luiz de Souza … Celi Marques-Santos João Bosco G. Rocha Joselina L. M. Oliveira Antônio C. S. Sousa José Augusto Barreto-Filho

BACKGROUND: From a mechanistic standpoint, obstructive sleep apnea (OSA) may further disturb cardiovascular homeostasis in the setting of acute coronary syndrome (ACS). OBJECTIVE: We sought to investigate if a standardized clinical diagnosis of OSA, in acute coronary syndrome patients, predicts the risk of cardiovascular events during hospitalization. METHODS: In a prospective cohort study, a group of 200 patients diagnosed with ACS between September 2005 and November 2007 were stratified by the Berlin Questionnaire (BQ) regarding the risk for OSA (high or low risk). We tested if the subgroup of high risk for OSA was prone to a higher frequency of cardiovascular events. The primary endpoint evaluated was a composite outcome of cardiovascular death, recurrent cardiac ischemic events, acute pulmonary edema and stroke during hospitalization. RESULTS: Ninety four (47%) patients assessed by the BQ were likely to have OSA. High risk for OSA was associated with a non-significant higher mortality (4.25% vs 0.94%; p=0.189), but a significant higher incidence of composite cardiovascular events (18.08% vs 6.6%; p=0.016). In the logistic regression model, multivariate predictors of composite cardiovascular events were age (OR= 1.048; 95% CI 1.008 to 1.090; p=0.019), left ventricular ejection fraction (OR= 0.954; 95% CI 0.920 to 0.989; p=0.010), and higher risk for OSA (OR= 3.657; 95% CI 1.216 to 10.996; p=0.021). CONCLUSION: The use of a simple and validated questionnaire (BQ) to identify patients with higher risk for OSA may help in the prediction of cardiovascular outcome during hospitalization. Moreover, our data suggests that OSA is very common in patients with ACS.

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