Clinical Adult Literature Updates from January 2014

Sleep Apnea is Associated With Subclinical Myocardial Injury in the Community: The ARIC-SHHS Study

In this population-based prospective cohort study, 1,645 adult participants free of coronary artery disease and heart failure participated in the Atherosclerosis Risk in the Communities (ARIC) and the Sleep Heart Health Studies (SHHS). They underwent overnight polysomnography and measurement of high sensitivity Troponin T (hs-TnT) – a marker of sub-myocardial injury; and N terminal pro B-type natriuretic peptide (NT-proBNP) – a marker of ventricular wall stress. After adjusting for confounders, OSA was independently associated with higher levels of hs-TNT and not NT-proBNP levels, indicating subclinical myocardial injury.


Educational, Supportive and Behavioral Interventions to Improve Usage of Continuous Positive Airway Pressure Machines in Adults With Obstructive Sleep Apnea

In this systematic review and meta-analysis, 30 studies (2047 participants) were included to evaluate educational, supportive and behavioral interventions that may be useful in increasing patient education and CPAP compliance and adherence. Low– to moderate-quality evidence showed that all three types of interventions led to increased machine usage in CPAP-naive participants with moderate to severe OSA syndrome. Optimal timing, duration and the number of such interventions may need to be optimized on an individual basis to increase CPAP education and compliance. More trials are also needed to evaluate the long-term effectiveness of these strategies.


Upper-Airway Stimulation for Obstructive Sleep Apnea

In this multicenter, prospective, uncontrolled, single-group cohort study, implantable upper-airway stimulation device (hypoglossal nerve stimulation) was evaluated in patents with obstructive sleep apnea having poor CPAP adherence or acceptance. Amongst the 126 included participants, median AHI score at 12 months decreased by 68% (from 29.3 to 9.0 events per hour) (P<0.001) and the ODI score decreased by 70% (from 25.4 to 7.4 events per hour) (P<0.001). There was also a reduction in the Epworth Sleepiness Scale to normal and increase of more than 3 points on the Functional Outcomes of Sleep Questionnaire after 12 months, in all participants. There were less than 2% side effects related to surgical procedure. This device could be useful in patients with poor CPAP tolerance and adherence, however more longitudinal data is required to evaluate the effects of factors such as significant weight gain, or medication use on the device efficacy.


Arrhythmia Risk Associated With Sleep Disordered Breathing in Chronic Heart Failure

The intersecting relationships of sleep disordered breathing (SDB), arrhythmogenic risk and chronic heart failure (HF) are complex and most likely multi-directional and synergistic. The current review focuses on the data, which have accrued elucidating the specific contributory mechanisms of SDB in cardiac arrhythmias and HF, highlighting the clinical relevance and effects of standard SDB treatment on these outcomes, and describing the role of novel therapeutics.

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

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.” Among approximately 200 “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.” These results may have a significant impact on preoperative planning.

Prevalence, Treatment and Outcomes Associated With Obstructive Sleep Apnea Among Patients Hospitalized With Pneumonia

Obstructive sleep apnea (OSA) is associated with increased risks of respiratory complications following surgery, however its relationship to the outcomes of hospitalized medical patients is unknown.” Using population based data analysis the authors conclude that “in patients hospitalized for pneumonia, OSA is associated with higher initial rates of mechanical ventilation, increased risk of clinical deterioration and higher resource utilization, yet a modestly lower risk of inpatient mortality.

Comparing a Combination of Validated Questionnaires and Level III Portable Monitor With Polysomnography to Diagnose and Exclude Sleep Apnea

Questionnaires alone, possibly given a reliance on sleepiness as a symptom, cannot reliably rule out the presence of OSA. Objective physiological measurement is critical for the diagnosis and exclusion of OSA.

The Role of Drug-Induced Sleep Endoscopy in the Diagnosis and Management of Obstructive Sleep Apnoea Syndrome: Our Personal Experience

The data suggests that drug induced sleep endoscopy (DISE) is safe, easy to perform, valid and reliable. Furthermore, a good correlation between DISE findings and clinical characteristics such as apnea hypopnea index and Epworth sleepiness score was found.

Excessive Daytime Sleepiness Increases the Risk of Motor Vehicle Crash in Obstructive Sleep Apnea

Untreated OSA is associated with an increased risk of near-misses in men and women and an increased risk of motor vehicle accidents in very sleepy men. There is a strong association between excessive daytime sleepiness and increased report of near-misses.

Post-Operative Outcomes in Adult Obstructive Sleep Apnea Patients Undergoing Non-Upper Airway Surgery: A Systematic Review and Meta-Analysis

The authors of this meta-analysis included 18 eligible studies. They found that OSA was associated with a significantly increased incidence of post-operative hypoxemia (odds ratio [OR] = 3.06; 95 % confidence interval [CI] 2.35–3.97), respiratory complications (OR = 2.77, 95 % CI 1.73–4.43), cardiac complications (OR = 1.76 95 % CI 1.16–2.67), neurological complications (OR = 2.65, 95 % CI 1.43–4.92), and unplanned intensive care unit (ICU) transfer (OR = 2.97, 95 % CI 1.90–4.64). They concluded that “OSA patients are at increased risk of post-operative complications from non-upper airway surgeries. Early diagnosis and treatment of OSA might decrease post-operative complications in these patients. There is a need for further studies to assess the benefit of peri-operative treatment of OSA on post-operative outcomes.