Bankstown Hospital - Grand Rounds - Further Reading

Welcome to the Grand Rounds Further Reading List, Cardiology edition, brought to you by the Clinical Library, on Level 4, next to the Auditorium.

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Arnaud, C., et al. (2020). "Obstructive sleep apnoea and cardiovascular consequences: Pathophysiological mechanisms." Arch Cardiovasc Dis 113(5): 350-358   1875-2128

Arnaud, Claire; Bochaton, Thomas; Pépin, Jean-Louis; Belaidi, Elise.

Arch Cardiovasc Dis. 2020 May;113(5):350-358.

doi: 10.1016/j.acvd.2020.01.003. Epub 2020 Mar 26.

https://www.sciencedirect.com/science/article/pii/S1875213620300413?via%3Dihub

                Obstructive sleep apnoea syndrome is a growing health concern, affecting nearly one billion people worldwide; it is an independent cardiovascular risk factor, associated with incident obesity, insulin resistance, hypertension, arrhythmias, stroke, coronary artery disease and heart failure. Obstructive sleep apnoea-related cardiovascular and metabolic co-morbidities are a major concern for prognosis and the complexity of obstructive sleep apnoea integrated care. Continuous positive airway pressure, the first-line therapy for the treatment of obstructive sleep apnoea, is highly effective at improving symptoms and quality of life, but has limited effect on co-morbidities. Deciphering the molecular pathways involved in obstructive sleep apnoea metabolic and cardiovascular consequences is a priority to make new pharmacological targets available, in combination with or as an alternative to continuous positive airway pressure. Intermittent hypoxia, a landmark feature of obstructive sleep apnoea, is the key intermediary mechanism underlying metabolic and cardiovascular complications. Experimental settings allowing intermittent hypoxia exposure in cells, rodents and healthy humans have been established to dissect the molecular mechanisms of obstructive sleep apnoea-related co-morbidities. The main objective of this review is to recapitulate the molecular pathways, cells and tissue interactions contributing to the cardiometabolic consequences of intermittent hypoxia. Sympathetic activation, low-grade inflammation, oxidative stress and endoplasmic reticulum stress are triggered by intermittent hypoxia and play a role in cardiometabolic dysfunction. The key role of hypoxia-inducible factor-1 transcription factor will be detailed, as well as the underestimated and less described importance of mitochondrial functional changes in the intermittent hypoxia setting.

Linz, D., et al. (2018). "Associations of Obstructive Sleep Apnea With Atrial Fibrillation and Continuous Positive Airway Pressure Treatment: A Review." JAMA Cardiol 3(6): 532-540   2380-6591

Linz, Dominik; McEvoy, R Doug; Cowie, Martin R; Somers, Virend K; Nattel, Stanley; Lévy, Patrick; Kalman, Jonathan M; Sanders, Prashanthan

JAMA Cardiol. 2018 Jun 1;3(6):532-540. doi: 10.1001/jamacardio.2018.0095.

https://pubmed.ncbi.nlm.nih.gov/29541763/

                IMPORTANCE: Obstructive sleep apnea (OSA) is the most common clinically significant breathing abnormality during sleep. It is highly prevalent among patients with atrial fibrillation (AF), and it promotes arrhythmogenesis and impairs treatment efficacy. OBSERVATIONS: The prevalence of OSA ranges from 3% to 49% in population-based studies and from 21% to 74% in patients with AF. Diagnosis and treatment of OSA in patients with AF requires a close interdisciplinary collaboration between electrophysiologists, cardiologists, and sleep specialists. Because the prevalence of OSA is high in patients with AF and most do not report daytime sleepiness, sleep-study evaluation may be reasonable for patients being considered for rhythm control strategy. Acute, transient apnea-associated atrial electrophysiological changes and increased occurrence of AF triggers associated with short episodes of intermittent deoxygenation and reoxygenation, intrathoracic pressure changes during obstructed breathing efforts, and sympathovagal activation combine to create a stimulus for AF triggers and a complex and dynamic substrate for AF during sleep. Repeated episodes of long-term OSA are eventually associated with structural remodeling and changes in electrical conduction in the atrium. Observational data suggest OSA reduces the efficacy of catheter-based and pharmacological antiarrhythmic therapy. Non-randomized studies have shown that treatment of OSA by continuous positive airway pressure can help to maintain a sinus rhythm after electrical cardioversion and catheter ablation in patients with AF. However, it remains unclear which sleep apnea metric should be used to determine severity and guide such treatment in patients with AF. CONCLUSIONS AND RELEVANCE: Data from nonrandomized studies of patients with AF suggest that treatment of OSA by continuous positive airway pressure may help to maintain sinus rhythm after electrical cardioversion and improve catheter ablation success rates. Randomized clinical trials are needed to confirm the association between OSA and AF the benefits of treatment of OSA and the need for and cost-effectiveness of routine OSA screening and treatment.

Mitra, A. K., et al. (2021). "Association and Risk Factors for Obstructive Sleep Apnea and Cardiovascular Diseases: A Systematic Review." Diseases 9(4)   2079-9721

Mitra, Amal K; Bhuiyan, Azad R; Jones, Elizabeth A

Diseases. 2021 Dec 2;9(4):88. doi: 10.3390/diseases9040088.

https://pubmed.ncbi.nlm.nih.gov/34940026/

                Obstructive sleep apnea (OSA) is a serious, potentially life-threatening condition. Epidemiologic studies show that sleep apnea increases cardiovascular diseases risk factors including hypertension, obesity, and diabetes mellitus. OSA is also responsible for serious illnesses such as congestive heart failure, stroke, arrhythmias, and bronchial asthma. The aim of this systematic review is to evaluate evidence for the association between OSA and cardiovascular disease morbidities and identify risk factors for the conditions. In a review of 34 studies conducted in 28 countries with a sample of 37,599 people, several comorbidities were identified in patients with severe OSA-these were: heart disease, stroke, kidney disease, asthma, COPD, acute heart failure, chronic heart failure, hyperlipidemia, thyroid disease, cerebral infarct or embolism, myocardial infarction, and psychological comorbidities including stress and depression. Important risk factors contributing to OSA included: age > 35 years; BMI ≥ 25 kg/m(2); alcoholism; higher Epworth sleepiness scale (ESS); mean apnea duration; oxygen desaturation index (ODI); and nocturnal oxygen desaturation (NOD). Severe OSA (AHI ≥ 30) was significantly associated with excessive daytime sleepiness and oxygen desaturation index. The risk of OSA and associated disease morbidities can be reduced by controlling overweight/obesity, alcoholism, smoking, hypertension, diabetes mellitus, and hyperlipidemia.

Moula, A. I., et al. (2022). "Obstructive Sleep Apnea and Atrial Fibrillation." J Clin Med 11(5)   2077-0383

Moula, Amalia Ioanna; Parrini, Iris; Tetta, Cecilia; Lucà, Fabiana; Parise, Gianmarco; Rao, Carmelo Massimiliano; Mauro, Emanuela; Parise, Orlando; Matteucci, Francesco; Gulizia, Michele Massimo

La Meir, Mark; Gelsomino, Sandr.

J Clin Med. 2022 Feb 25;11(5):1242. doi: 10.3390/jcm11051242.

https://pubmed.ncbi.nlm.nih.gov/35268335/

                Atrial fibrillation (AF) is the most common arrhythmia, increasing with age and comorbidities. Obstructive sleep apnea (OSA) is a chronic sleep disorder more common in older men. It has been shown that OSA is linked to AF. Nonetheless, the prevalence of OSA in patients with AF remains unknown because OSA is significantly underdiagnosed. This review, including 54,271 patients, carried out a meta-analysis to investigate the association between OSA and AF. We also performed a meta-regression to explore cofactors influencing this correlation. A strong link was found between these two disorders. The incidence of AF is 88% higher in patients with OSA. Age and hypertension independently strengthened this association, indicating that OSA treatment could help reduce AF recurrence. Further research is needed to confirm these findings. Atrial Fibrillation (AF) is the most common arrhythmia, increasing with age and comorbidities. Obstructive sleep apnea (OSA) is a regulatory respiratory disorder of partial or complete collapse of the upper airways during sleep leading to recurrent pauses in breathing. OSA is more common in older men. Evidence exists that OSA is linked to AF. Nonetheless, the prevalence of OSA in patients with AF remains unknown because OSA is underdiagnosed. In order to investigate the incidence of AF in OSA patients, we carried out a meta-analysis including 20 scientific studies with a total of 54,271 subjects. AF was present in 4801 patients of whom 2203 (45.9%) had OSA and 2598 (54.1%) did not. Of a total of 21,074 patients with OSA, 2203 (10.5%) had AF and 18,871 (89.5%) did not. The incidence of AF was 88% higher in patients with OSA. We performed a meta-regression to explore interacting factors potentially influencing the occurrence of AF in OSA. Older age and hypertension independently strengthened this association. The clinical significance of our results is that patients with OSA should be referred early to the cardiologist. Further research is needed for the definition of the mechanisms of association between AF and OSA.

Yeghiazarians, Y., et al. (2021). "Obstructive Sleep Apnea and Cardiovascular Disease: A Scientific Statement From the American Heart Association." Circulation 144(3): e56-e67   1524-4539

Yeghiazarians, Yerem; Jneid, Hani; Tietjens, Jeremy R; Redline, Susan; Brown, Devin L; El-Sherif, Nabil;

Mehra, Reena; Bozkurt, Biykem; Ndumele, Chiadi Ericson; Somers, Virend K.

Circulation. 2021 Jul 20;144(3):e56-e67.

doi: 10.1161/CIR.0000000000000988. Epub 2021 Jun 21.

https://pubmed.ncbi.nlm.nih.gov/34148375/

                Obstructive sleep apnea (OSA) is characterized by recurrent complete and partial upper airway obstructive events, resulting in intermittent hypoxemia, autonomic fluctuation, and sleep fragmentation. Approximately 34% and 17% of middle-aged men and women, respectively, meet the diagnostic criteria for OSA. Sleep disturbances are common and underdiagnosed among middle-aged and older adults, and the prevalence varies by race/ethnicity, sex, and obesity status. OSA prevalence is as high as 40% to 80% in patients with hypertension, heart failure, coronary artery disease, pulmonary hypertension, atrial fibrillation, and stroke. Despite its high prevalence in patients with heart disease and the vulnerability of cardiac patients to OSA-related stressors and adverse cardiovascular outcomes, OSA is often underrecognized and undertreated in cardiovascular practice. We recommend screening for OSA in patients with resistant/poorly controlled hypertension, pulmonary hypertension, and recurrent atrial fibrillation after either cardioversion or ablation. In patients with New York Heart Association class II to IV heart failure and suspicion of sleep-disordered breathing or excessive daytime sleepiness, a formal sleep assessment is reasonable. In patients with tachy-brady syndrome or ventricular tachycardia or survivors of sudden cardiac death in whom sleep apnea is suspected after a comprehensive sleep assessment, evaluation for sleep apnea should be considered. After stroke, clinical equipoise exists with respect to screening and treatment. Patients with nocturnally occurring angina, myocardial infarction, arrhythmias, or appropriate shocks from implanted cardioverter-defibrillators may be especially likely to have comorbid sleep apnea. All patients with OSA should be considered for treatment, including behavioral modifications and weight loss as indicated. Continuous positive airway pressure should be offered to patients with severe OSA, whereas oral appliances can be considered for those with mild to moderate OSA or for continuous positive airway pressure-intolerant patients. Follow-up sleep testing should be performed to assess the effectiveness of treatment.

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