Francisco Capote

Long-term effect of continuous positive airway pressure in hypertensive patients with sleep apnea.

RATIONALEnContinuous positive airway pressure (CPAP) is the current treatment for patients with symptomatic obstructive sleep apnea (OSA). Its use for all subjects with sleep-disordered breathing, regardless of daytime symptoms, is unclear.nnnOBJECTIVESnThis multicenter controlled trial assesses the effects of 1 year of CPAP treatment on blood pressure (BP) in nonsymptomatic, hypertensive patients with OSA.nnnMETHODSnWe evaluated 359 patients with OSA. Inclusion criteria consisted of an apnea-hypopnea index (AHI) greater than 19 hour(-1), an Epworth Sleepiness Scale score less than 11, and one of the following: under antihypertensive treatment or systolic blood pressure greater than 140 or diastolic blood pressure greater than 90 mm Hg. Patients were randomized to CPAP (n = 178) or to conservative treatment (n = 181). BP was evaluated at baseline and at 3, 6, and 12 months of follow-up.nnnMEASUREMENTS AND MAIN RESULTSnMean (SD) values were as follows: age, 56 +/- 10 years; body mass index (BMI), 32 +/- 5 kg x m(-2); AHI, 45 +/- 20 hour(-1); and Epworth Sleepiness Scale score, 7 +/- 3. After adjusting for follow-up time, baseline blood pressure values, AHI, time with arterial oxygen saturation less than 90%, and BMI, together with the change in BMI at follow-up, CPAP treatment decreased systolic blood pressure by 1.89 mm Hg (95% confidence interval: -3.90, 0.11 mm Hg; P = 0.0654), and diastolic blood pressure by 2.19 mm Hg (95% confidence interval: -3.46, -0.93 mm Hg; P = 0.0008). The most significant reduction in BP was in patients who used CPAP for more than 5.6 hours per night. CPAP compliance was related to AHI and the decrease in Epworth Sleepiness Scale score.nnnCONCLUSIONSnIn nonsleepy hypertensive patients with OSA, CPAP treatment for 1 year is associated with a small decrease in BP. This effect is evident only in patients who use CPAP for more than 5.6 hours per night. Clinical trial registered with www.clinicaltrials.gov (NCT00127348).

Effect of CPAP on Blood Pressure in Patients With Obstructive Sleep Apnea and Resistant Hypertension The HIPARCO Randomized Clinical Trial

IMPORTANCEnMore 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.nnnOBJECTIVEnTo assess the effect of CPAP treatment on blood pressure values and nocturnal blood pressure patterns in patients with resistant hypertension and OSA.nnnDESIGN, SETTING, AND PARTICIPANTSnOpen-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.nnnINTERVENTIONSnCPAP or no therapy while maintaining usual blood pressure control medication.nnnMAIN OUTCOMES AND MEASURESnThe 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.nnnRESULTSnA total of 194 patients were randomly assigned to receive CPAP (nu2009=u200998) or no CPAP (control; nu2009=u200996). 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]; Pu2009=u2009.02) and 24-hour DBP (3.2 mm Hg [95% CI, 1.0 to 5.4]; Pu2009=u2009.005), but not in 24-hour SBP (3.1 mm Hg [95% CI, -0.6 to 6.7]; Pu2009=u2009.10) 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]; Pu2009=u2009.02). There was a significant positive correlation between hours of CPAP use and the decrease in 24-hour mean blood pressure (ru2009=u20090.29, Pu2009=u2009.006), SBP (ru2009=u20090.25; Pu2009=u2009.02), and DBP (ru2009=u20090.30, Pu2009=u2009.005).nnnCONCLUSIONS AND RELEVANCEnAmong 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.nnnTRIAL REGISTRATIONnclinicaltrials.gov Identifier: NCT00616265.

Daytime sleepiness and polysomnography in obstructive sleep apnea patients

BACKGROUNDnExcessive daytime sleepiness (EDS) is the major complaint in subjects with obstructive sleep apnea syndrome (OSAS). However, EDS is not universally present in all patients with OSAS. The mechanisms explaining why some patients with OSAS complain of EDS whereas others do not are unknown.nnnOBJECTIVEnTo investigate polysomnographic determinants of excessive daytime sleepiness (EDS) in a large multicenter cohort of patients with obstructive sleep apnea (OSAS).nnnMETHODSnAll consecutive patients with an apnea-hypopnea index greater than 5h(-1) who were evaluated between 2003 and 2005. EDS was assessed using the Epworth Sleepiness Scale (ESS), and patients were considered to have EDS if the ESS was >10.nnnRESULTSnA total of 1649 patients with EDS ((mean [+/-SD] Epworth 15+/-3) and 1233 without EDS (Epworth 7+/-3) were studied. Patients with EDS were slightly younger than patients without EDS (51+/-12 vs 54+/-13 years, p<0.0001), had longer total sleep time (p<0.007), shorter sleep latency (p<0001), greater sleep efficiency (p<0.0001) and less NREM sleep in stages 1 and 2 (p<0.007) than those without EDS. Furthermore, patients with EDS had slightly higher AHI (p<0.005) and arousal index (p<0.001) and lower nadir oxygen saturation (p<0.01).nnnCONCLUSIONSnPatients with OSAS and EDS are characterized by longer sleep duration and increased slow wave sleep compared to those without EDS. Although patients with EDS showed a mild worsening of respiratory disturbance and sleep fragmentation, these results suggest that sleep apnea and sleep disruption are not the primary determinants of EDS in all of these patients.

Home respiratory polygraphy for diagnosis of sleep-disordered breathing in heart failure

The present study assessed the usefulness of home cardiorespiratory polygraphy as an alternative to overnight polysomnography for the diagnosis of sleep-disordered breathing in heart failure. A total of 75 patients with chronic stable heart failure due to systolic dysfunction (left ventricular ejection fraction ≤45%) underwent polysomnography at the Virgen del Rocio Hospital and cardiorespiratory polygraphy at home. The two studies were performed in random order and within 30 days. The accuracy of polygraphical findings was determined by sensitivity and specificity obtained by area under the receiver operating characteristics (ROC) curves for apnoea-hypopnoea index (AHI) thresholds of ≥5, ≥10 and ≥15 in the polysomnography. The area under the ROC curve for AHI ≥5, ≥10 and ≥15 was 0.896, 0.907 and 0.862, respectively. The diagnostic accuracy of polygraphy compared with polysomnography ranged 78.6–84%, with sensitivities of 68.4–82.5%, and specificities of 88.6–97.8% for the different AHI thresholds. Altogether, 29 patients had an AHI ≥10 (central pattern 24, obstructive pattern 5). Sensitivity and specificity of home polygraphy for identifying the sleep-disordered breathing pattern was 100%. These data show that home cardiorespiratory polygraphy has a high sensitivity and specificity for the diagnosis of sleep-disordered breathing associated with heart failure.

Efficacy of continuous positive airway pressure treatment on 5-year survival in patients with ischaemic stroke and obstructive sleep apnea: a randomized controlled trial

The main purpose of the present analysis is to assess the influence of introducing early nasal continuous positive airway pressure (nCPAP) treatment on cardiovascular recurrences and mortality in patients with a first‐ever ischaemic stroke and moderate–severe obstructive sleep apnea (OSA) with an apnea–hypopnea index (AHI) ≥20 events h−1 during a 5‐year follow‐up. Patients received conventional treatment for stroke and were assigned randomly to the nCPAP group (n = 71) or the control group (n = 69). Cardiovascular events and mortality were registered for all patients. Survival and cardiovascular event‐free survival analysis were performed after 5‐year follow‐up using the Kaplan–Meier test. Patients in the nCPAP group had significantly higher cardiovascular survival than the control group (100 versus 89.9%, log‐rank test 5.887; P = 0.015) However, and also despite a positive tendency, there were no significant differences in the cardiovascular event‐free survival at 68 months between the nCPAP and control groups (89.5 versus 75.4%, log‐rank test 3.565; P = 0.059). Early nCPAP therapy has a positive effect on long‐term survival in ischaemic stroke patients and moderate–severe OSA.

Respiratory Polygraphy With Actigraphy in the Diagnosis of Sleep Apnea-Hypopnea Syndrome

OBJECTIVEnTo determine the utility and reliability of a respiratory polygraphy (RP) device with actigraphy (Apnoescreen II; Erich Jaeger GMBH & CoKg; Wuerzburg, Germany) in the diagnosis of sleep apnea-hypopnea syndrome (SAHS).nnnDESIGNnA prospective randomized study with blinded analysis.nnnPATIENTSnSixty-two patients with suspected SAHS.nnnMEASUREMENTSnthe following two RP studies were performed: one in the sleep laboratory (sleep laboratory RP [LRP]), simultaneously with polysomnography; and the other at home (home RP [HRP]). To study the interobserver reliability of RP, two manual analyses were carried out by two different researchers.nnnRESULTSnIn LRP, when the respiratory disturbance index was calculated using the total sleep time estimated by actigraphy (RDI) as a denominator, the sensitivity ranged between 94.6% and 100%, and the specificity between 88% and 96.7% for the different cutoff points of the apnea-hypopnea indexes studied. When the respiratory disturbance index was calculated according to the total recording time (RDITRT), the sensitivity was slightly lower (91.6 to 96.9%) and the specificity was similar (92 to 96.7%). In HRP, the sensitivity of the RDI ranged between 83.8% and 95.8%, and the specificity between 92% and 100%, whereas, when the RDITRT was used, the sensitivity was between 83.8% and 87.5%, and the specificity was between 94.7% and 100%. With regard to interobserver reliability, the intraclass correlation coefficient for the RDI of the two analyses of the RP was 0.99 for both LPR and HPR.nnnCONCLUSIONnHPR is an effective and reliable technique for the diagnosis of SAHS, although it is less sensitive than LRP. Wrist actigraphy improves the results of HRP only slightly.

Quality of life in patients with congestive heart failure and central sleep apnea

OBJECTIVEnTo assess the impact of Cheyne-Stoke respiration-central sleep apnea (CSR-CSA) on quality of life (QOL) in patients with congestive heart failure (CHF). QOL was established using the MLHFQ (Minnesota Living with Heart Failure Questionnaire), and the FOSQ (Functional Outcomes of Sleep Questionnaire).nnnMETHODSnWe examined 90 patients with CHF. The diagnosis of CSR-CSA was performed by polysomnography. We established a correlation between the apnea-hypopnea index (AHI) and the MLHFQ and FOSQ scores.nnnRESULTSnFive patients were excluded (obstructive sleep apnea). Of the 85 remaining patients, 25 presented CSR-CSA. The mean MLHFQ score was higher in patients with CHF and CSR-CSA (25.8+/-2.97 vs. 16.6+/-2.05; p=0.01), and showed a significant yet moderate correlation with the AHI. A lower mean FOSQ score was obtained for the group of patients with CHF and CSR-CSA (78.4+/-4.31 vs. 88.47+/-2.4; p=0.03), showing weak negative correlation with the AHI.nnnCONCLUSIONnAccording to the MLHFQ scores, it seems that CHF patients with CSR-CSA have a worse QOL than those with CHF alone. Although this could be attributable to a greater impairment of heart function in the former group, the FOSQ scores indicate some influence of their sleep disorder on the impairment of QOL.

[Blood uric acid levels in patients with sleep-disordered breathing].

OBJECTIVEnRecurrent hypoxia associated with sleep apnea-hypopnea syndrome (SAHS) leads to an increase in the degradation of adenosine triphosphatase to xanthine and, secondarily, to an increase in uric acid concentrations. The aim of the present study was to determine whether there is a correlation between uric acid levels in peripheral blood and sleep-disordered breathing, independently of known confounding factors.nnnPATIENTS AND METHODSnWe carried out a retrospective cross-sectional study of 1135 patients evaluated for suspected SAHS. For all patients, a medical history was taken using a standardized protocol. In addition, biochemical analysis of venous blood and an overnight sleep study (with either conventional polysomnography or home monitoring) were carried out.nnnRESULTSnThe mean (SD) concentration of uric acid was 6.31 (1.5) mg/dL, and 36% of patients had concentrations above established normal values for their sex. We found a significant correlation between uric acid levels and some sleep study parameters (number of respiratory events, number of desaturations, or the cumulative percentage of time with oxygen saturation less than 90%). Those patients with more respiratory events (apnea-hypopnea index or respiratory event index >or= 30) had higher uric acid levels than those with mild or no SAHS. However, this difference was not apparent in the univariate analysis of variance, in which body mass index and cholesterol and triglyceride levels were considered confounding factors.nnnCONCLUSIONSnUric acid levels are positively correlated with the number of obstructive respiratory episodes and oxygen desaturations during sleep, but this correlation seems to be influenced by other factors, such as obesity.

Valores de ácido úrico en sangre en pacientes con trastornos respiratorios del sueño

Objetivo: La hipoxia recurrente del sindrome de apnea-hipopnea durante el sueno (SAHS) origina un aumento de la degradacion de adenosintrifosfato a xantina y, secundariamente, de las concentraciones de acido urico. El proposito del presente estudio ha sido analizar si existe relacion entre los valores de acido urico en sangre periferica y los trastornos respiratorios durante el sueno, independientemente de los factores de confusion conocidos. nnPacientes y metodos: Se ha realizado un estudio transversal retrospectivo con 1.135 pacientes evaluados por sospecha de SAHS. A todos ellos se les realizaron una historia clinica protocolizada, un estudio bioquimico de sangre venosa y un estudio de sueno nocturno (polisomnografia convencional o poligrafia domiciliaria). nnResultados: El valor medio (± desviacion estandar) del acido urico fue de 6,31 ± 1,5 mg/dl, y el 36% de los pacientes presentaban unas concentraciones de uricemia superiores a las establecidas como normales segun el sexo. Encontramos una correlacion significativa entre los valores de acido urico y algunos parametros de los estudios de sueno (numero de eventos respiratorios, numero de desaturaciones o el porcentaje de registro con saturacion < 90%). Los pacientes con mayor numero de eventos respiratorios (indice de apneas-hipopneas o indice de eventos respiratorios = 30) tenian un valor mas alto de acido urico que aquellos sin SAHS o con SAHS leve, aunque esta diferencia desaparecio al realizar un analisis de la variancia univariante en el que se consideraron factores de confusion el indice de masa corporal y los valores de colesterol y trigliceridos. nnConclusiones: Los valores de uricemia aumentan a medida que lo hacen los episodios respiratorios obstructivos y las desaturaciones durante el sueno, pero este aumento parece condicionado por varios factores, como la obesidad.

Influencia del sexo en las variables clínicas y polisomnográficas del síndrome de apneas del sueño

Objetivo nComparar, en una cohorte amplia de pacientes con sindrome de apneas-hipopneas durante el sueno, las caracteristicas clinicas, antropometricas y polisomnograficas en funcion del sexo. nPacientes y metodos nEn el estudio, realizado en 6 hospitales universitarios espanoles, se incluyo a pacientes consecutivos con un indice de apneas-hipopneas del sueno mayor de 5 h−1, que fueron evaluados entre 2003 y 2005. Se dividieron en funcion del sexo y, posteriormente, en funcion de la edad: pacientes jovenes (45 anos) y adultos (> 45 anos). nResultados nSe ha estudiado a 2.464 varones y 424 mujeres. Las mujeres eran mayores (edad media ± desviacion estandar: 56 ± 12 frente a 51 ± 12 anos; p < 0,0001), pesaban mas (indice de masa corporal: 31 ± 6 frente a 30 ± 5 kg/m2; p < 0,0001) y presentaban una mayor circunferencia de cadera (119 ± 15 frente a 111 ± 12 cm; p < 0,0001) y una menor circunferencia de cuello (38 ± 3 frente a 42 ± 9 cm; p < 0,0001) que los varones. El grado de somnolencia diurna (escala de Epworth) y el indice de apneas-hipopneas eran similares en ambos grupos, aunque el de mujeres presentaba una latencia de sueno mas larga (23 ± 28 frente a 27 ± 32 min; p < 0,004) y una saturacion de oxigeno media (un 92 ± 4 frente a un 91 ± 5%) y minima menor (un 78 ± 11 frente a un 75 ± 12%; p < 0,0001) que los varones. Al diferenciar los grupos por edad, en el grupo de jovenes solo se mantenian las diferencias ponderales, mientras que entre los adultos reaparecian las diferencias en los valores de saturacion nocturna. nConclusiones nLas mujeres con sindrome de apneas-hipopneas durante el sueno son mas obesas que los varones y consultan a una edad mas avanzada. Desde el punto de vista clinico y polisomnografico, no hay grandes diferencias en funcion del sexo. Unicamente la latencia de sueno es superior y la hipoxemia nocturna mas acentuada.