Sleep-disordered breathing is associated with depletion of circulating endothelial progenitor cells and elevation in pulmonary arterial pressure in patients with decompensated systolic heart failure

Background Sleep-disordered breathing （SDB） is known to occur frequently in and may predict worsening progression of patients with congestive heart failure （CHF）. SDB is also known to play an important role in the development of idiopathic pulmonary arterial hyper- tension （PAH） via inducing endothelial dysfunction and vascular remodeling, a pathological process that can be significantly influenced by factors such as osteoprotegerin （OPG） and endothelial progenitor cells （EPCs）. The objective of this study is to determine if CHF with SDB is associated with changes in OPG, EPCs, and PAIl. Methods EPCs were isolated, cultured, and quantified from CHF patients with SDB （n = 52）, or without SDB （n - 68）. OPG and N-terminal pro-brain natriuretic peptide （NT-proBNP） from each group was analyzed and cor- related with EPCs and the mean pulmonary artery pressure （mPAP） measured by right heart catheterization. Results A significant decrease in circulating EPCs （29.30 ± 9.01 vs. 45.17 ± 10.51 EPCs/x 200 field; P 〈 0.05） was found in CHF patients with SDB compared to those without SDB. Both OPG （789.83 ±89.38 vs. 551.29 ± 42.12 pg/mL; P 〈 0.05） and NT-proBNP （5946.50 ± 1434.50 vs. 3028.60 ± 811.90 ng/mL; P 〈 0.05） were also significantly elevated in SDB CHF patients who also had significantly elevated mPAP （50.2 ± 9.5 vs. 36.4 ± 4.1 mm Hg; P 〈 0.05）. EPC numbers correlated inversely with the episodes of apnea and hypopnea per hour （RDI, r = -0.45, P = 0.037） and blood level of OPG （r =-0.53, P = 0.011）. Although NT-proBNP was also increased significantly in patients with SDB, it had no correlation with either EPCs or RD1. Conclusions SDBdue to hypoxemia from decompensated CHF is associated with （1） OPG elevation, （2） EPC depletion, and （3） mPAP elevation. The inverse relationship of circulating OPG with EPCs suggests a likely mechanism for hypoxemia and OPG in the development of pulmonary vascular dysfunction via depleting EPCs, thus worsening prognosis of CHF.

Effect of continuous positive airway pressure ventilation on nocturnal ST-segment changes in patients with sleep-disordered breathing

Objective To determine whether sleep-disordered breathing (SDB) may lead to nocturnal myocardial ischemia and whether the severity of this ischemia may be relieved by nasal continuous positive airway pressure (CPAP). Methods Overnight polysomnogram examination and simultaneous 3-channel Holter monitoring were performed on 76 patients with moderate to severe SDB and no history of coronary heart disease. All the cases were treated with CPAP for one night. ST depression was defined as a ST segment decrease of more than 1 mm from baseline and lasting 1 min or more. The total duration (minutes) of ST depression was indexed to the total sleep time (minutes per hour of sleep). Results Twenty-eight patients (37%) showed ST segment depression during their sleep. Before CPAP treatment, the respiratory disturbance index (RDI) and arousal index were significantly higher during periods of ST depression than when ST segments were isoelectric, whereas no significant difference was found in blood oxygen saturation (SaO2). After the CPAP treatment of patients with ST depression, the duration of ST depression was significantly reduced from 36.8±18.9 to 11.4±13.2 min/h (P<0.05). ST depression-related indexes, including RDI, arousal index and the percentage of sleep time spent at SaO2 below 90% (TS90/ TST), were all significantly decreased, with RDI from 63.4±23.8 to 8.1±6.6 /h, arousal index from 51.2±18.9 to 9.6±5.4 /h, and TS90/ TST from 50.6±21.4 to 12.9±14.7% (P<0.05). Conclusion ST-segment depression is rather common in patients with moderate to severe SDB, and CPAP treatment can significantly reduce the duration of ST depression. ST depression in these patients may reflect the myocardial ischemia that really exists and the non-ischemic changes associated with recurrent SDB.

Prevalence of sleep-disordered breathing in elderly patients with cardiac pacemaker: a case-control study

Objective To investigate the prevalence of sleep-disordered breathing in elderly patients with permanent cardiac pacemaker implantation due to bradyarrhythmias, and the relationship between pacing mode and patients' sleep apnea-hypopnea index.Methods Forty-four elderly patients (＞60 years) with cardiac pacemaker and their 44 controls matched for gender, age, body mass index and cardiovascular morbidity were studied using polysomnography or portable sleep monitoring device. Results Prevalence of sleep-disordered breathing (apnea-hypopnea index ≥5/h) was 44.7% and the mean apnea-hypopnea index was 8.2 ±4.1/h in the cardiac pacemaker group, which were significantly higher than those in control subjects (25% and 4.6±2.4/h, respectively, P＜0.01 and P＜0.05). The mean apnea-hypopnea index of patients with DDD or AAI pacemaker was significantly lower than that of patients with VVI pacemaker. Conclusions Sleep-disordered breathing was more common in patients who had their cardiac pacemaker implanted due to bradyarrhythmias than in their matched controls. Compared with VVI pacing, DDD or AAI pacing may be more beneficial to patients with bradyarrhythmias and sleep-disordered breathing.

Nocturnal myocardial ischemic events and sleep-disordered breathing in patients with coronary artery disease

Objective To investigate the occurrence of nocturnal myocardial ischemia and its relationship with sleep-disordered breathing (apneas and oxygen desaturations) in patients with angina pectoris undergoing coronary angiography.Methods Eighty-two men and 14 women referred for consideration of coronary intervention were randomly selected. Observation by an overnight sleep monitor and Holter recording were performed to study sleep-disordered breathing (oxyhemoglobin desaturations≥4% and apnea-hypopneas),heart rates, and ST-segment depressions (≥ 1mm, ≥1 min).Results Nocturnal ST-segment depressions occurred in 37 % of the patients. ST-segment depression within 2 min after an apnea-hypopnea or desaturation occurred in 17% of the patients. This temporal association was seen in 21% of the patients with nocturnal ST-segment depressions, more frequently in men (P<0.05) and more frequently in those with severe disordered breathing (P<0.05).Most of these ST-segment depressions were preceded by a series of breathing events: repeated apnea-hypopneas or desaturations or both in 73% of the patients. Conclusions Episodes of nocturnal myocardial ischemia are common in patients with angina pectoris. A temporal relationship between sleep-disordered breathing and myocardial ischemia was present in some of our patients, and occurs more frequently in men and in those with severely disordered breathing. (J Geriatr Cardiol 2004;1(2):90-94.)

Sleep-disordered breathing and stroke:A relation to be considered

Stroke is a leading cause of death and disability.Despite expensive and elaborative research in finding out mechanisms of interrelation between sleep-disordered breathing(SDB)and stroke,there is yet much attention to be given in stroke units worldwide to the prompt diagnosis and treatment of SDB in order to improve morbidity and mortality rates related with stroke.The preventive diagnosis and treatment of SDB reduce stroke rate and improves penumbra area in case of ischemic stroke.Stroke itself predispose to SDB,making the interrelationship more complicated.The review by Parra O and Arboix A reflects the results from carefully selected reviews reported in the literature so far.This review of the literature and presentation of the original study of the Authors based on their patients’data,enhances the conviction that there exists a direct relation between SDB and stroke.Diagnosis of SDB in new stroke cases should be sought and treated carefully whenever present.

Immune function in Japanese schoolchildren with sleep-disordered breathing: a preliminary study with analyses of salivary markers

The aim of this study was to assess the prevalence of sleep-disordered breathing (SDB) symptoms among primary schoolchildren, and to objectively determine the influence of SDB on the intra-oral environment through the analysis of saliva. A questionnaire survey was conducted among approximately 400 children from a primary school in Hiroshima. Parents were asked to complete the questionnaire and provide their contact information if they allowed the collection of saliva samples from their children. Thirty-eight chil- dren agreed to participate in the saliva study. Habit- ual snoring and cessation of breathing during sleep were found in approximately 8% and 1% of children, respectively. The present results showed significant correlations between snoring and mouth breathing. A significant association between excessive daytime sle- epiness (EDS) and learning problems was found. Fur- thermore, among children between the ages of 7 and 12 years, those with EDS and learning problems tended to be older. SDB symptom scores were statisti- cally significant only in relation to EDS. The present study also demonstrated significantly higher levels of salivary IgA and cortisol in children with sleep-re- lated disorders. The present study determined the pre- valence and characteristics of SDB among Japanese primary schoolchildren and their effects on the oral environment. Approximately 8% of primary school- children with habitual snoring might need to be care- fully monitored for SDB symptoms and immune sta- tus to ensure proper psychological and physical deve- lopment.

Sleep disorders in Alzheimer’s disease:the predictive roles and potential mechanisms

Sleep disorders are common in patients with Alzheimer’s disease,and can even occur in patients with amnestic mild cognitive impairment,which appears before Alzheimer’s disease.Sleep disorders further impair cognitive function and accelerate the accumulation of amyloid-βand tau in patients with Alzheimer’s disease.At present,sleep disorders are considered as a risk factor for,and may be a predictor of,Alzheimer’s disease development.Given that sleep disorders are encountered in other types of dementia and psychiatric conditions,sleep-related biomarkers to predict Alzheimer’s disease need to have high specificity and sensitivity.Here,we summarize the major Alzheimer’s disease-specific sleep changes,including abnormal non-rapid eye movement sleep,sleep fragmentation,and sleep-disordered breathing,and describe their ability to predict the onset of Alzheimer’s disease at its earliest stages.Understanding the mechanisms underlying these sleep changes is also crucial if we are to clarify the role of sleep in Alzheimer’s disease.This paper therefore explores some potential mechanisms that may contribute to sleep disorders,including dysregulation of the orexinergic,glutamatergic,andγ-aminobutyric acid systems and the circadian rhythm,together with amyloid-βaccumulation.This review could provide a theoretical basis for the development of drugs to treat Alzheimer’s disease based on sleep disorders in future work.

Continuous respiratory monitoring for sleep apnea screening by ambulatory hemodynamic monitor

AIM:To validate the sleep-disordered breathing components of a portable electrocardiography and hemodynamic monitor to be used for sleep apnea screening.METHODS:Sleep-disordered breathing(SDB) is associated with cardiovascular disease.Patients with existing cardiovascular disease may have unrecognized SDB or may develop SDB while under the care of a cardiologist.A screening device for SDB,easy to use and appealing to cardiologists,would assist in referral of appropriate patients for full polysomnography(PSG).A cardiac and respiratory monitor(CPAM) was attached to patients undergoing PSG and an apnea/hypopnea index(AHI) generated.The CPAM device produced respiration rate,snoring rate,individual apnea/hypopnea events and an SDB severity score(SDBSS).In addition to AHI,an expert over-reader annotated individual breaths,snores and SDB breathing events to which the automated algorithms were compared.RESULTS:The test set consisted of data from 85 patients(age:50.5 ± 12.4 years).Of these,57 had a positive PSG defined as AHI ≥ 5.0(mean:30.0 ± 29.8,negative group mean:1.5 ± 1.2).The sensitivity and specificity of the SDBSS compared to AHI was 57.9% and 89.3%,respectively.The correlation of snoring rate by CPAM compared to the expert overreader was r = 0.58(mean error:1.52 snores/min),while the automated respiration rate had a correlation of r = 0.90(mean error:0.70 breaths/min).CONCLUSION:This performance assessment shows that CPAM can be a useful portable monitor for screening and follow-up of subjects for SDB.

Characteristics of Electroencephalogram Arousals of Sleep- disordered Breathing Children at Different Sleep Stages

Sleep-disordered breathing （SDB） is the most common sleep- related disorder, and it can seriously affect sleep conditions, growth, and neurocognitive function. Recent research even demonstrates that hypertensive patients with SDB are at an increased risk of developing resistant hypertension.

睡眠呼吸紊乱儿童脑电醒觉反应研究进展

本文对睡眠呼吸紊乱儿童脑电醒觉反应的定义及分类、相关指数及变化特点和研究脑电醒觉反应的模式进行综述,从而更清楚准确的了解其微观睡眠结构的变化特点,以便更好的解释相应的临床特点.

Application of drug-induced sleep endoscopy in patients treated with upper airway stimulation therapy

Objective:To determine the level of agreement among experienced operators of candidacy for upper airway stimulation (UAS) based on evaluation of drug-induced sleep endoscopy (DISE).Methods:The trial was designed as a single-blinded cross-sectional study.Four otolaryngologists with extensive DISE experience were given 63 video clips from the STAR trial video library.These videos were graded using the VOTE classification.Percentage agreement and Cohen's k (for inter-rater reliability) were calculated between pairs of reviewers,assessing palatal complete concentric collapse (CCC) and determining UAS eligibility.Subjects were also grouped based on collapse severity for each reviewer.Results:The reviewers had excellent (approximately 90％) agreement on findings at the level of the soft palate and tongue base.The inter-rater reliability for palatal CCC ranged from mod erate to substantial The agreement on determining the criteria for UAS implantation ranged from poor to moderate.All 4 upper airway structures as classified by the criteria of the VOTE were graded by all the reviewers as contributing to obstruction in a majority of subjects who were performed via application of DISE.Conclusion:Application of DISE remains a subjective examination,even among those experienced operators,therefore more studies need to be performed for evaluation of improvement in inter-rater reliability after implantation of training videos.

Dilated cardiomyopathy is associated with increased prevalence of sleep apnea

Background Sleep apnea（SA） is a common disorder in general population, especially cardiovascular disease （CVD） patients. However, its role in cardiomyopathy etiology is still unclear. Methods In this single-center observational study, we enrolled 2740 CVD patients consecutively from 2013 to 2016. Among study subjects, 65 were diagnosed as idiopathic dilated cardiomyopathy（DCM） and 34 were hypertrophic cardiomyopathy（HCM）. Patients underwent sleep study with portable monitoring devices and diagnosed as non-SA （AHI〈5）, mild （5-≤ AHI≤15）, moderate （15〈AHI≤30） or severe SA （AHI〉30） using the apnea-hypopnea index （AHI）. Central sleep apnea（CSA） and obstructive sleep apnea（OSA） were defined by central event percentage, with 50% as cut-value. Results The prevalence of SA was higher in DCM patients. While the prevalence of moderate to severe SA was similar in HCM and other CVD patients （32.4% vs. 34.3%, P 〉0.1）, it was significantly higher in DCM patients （49.2%, P =0.017 vs. other CVD patients）. The prevalence of CSA in DCM patients was also higher than other CVD patients （9.2% vs. 3.2%, P〈0.01）, but the difference of OSA was not statistically significant （40.0% vs. 30.3%, P =0.229）. In comparison to other heart failure with reduced ejection fraction （HFrEF） patients, the result was nearly at the same level. Conclusions SA is more common in idiopathic dilated cardiomyopathy patients. Prevalence of moderate to severe SA and CSA is higher in idiopathic HCM patients than other CVD and HFrEF patients.