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Obstructive sleep apnoea in acute coronary syndrome

Winfried Randerath, Maria R. Bonsignore, Simon Herkenrath
European Respiratory Review 2019 28: 180114; DOI: 10.1183/16000617.0114-2018
Winfried Randerath
1Institute of Pneumology at the University of Cologne, Bethanien Hospital, Clinic for Pneumology and Allergology, Centre of Sleep Medicine and Respiratory Care, Solingen, Germany
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  • For correspondence: randerath@klinik-bethanien.de
Maria R. Bonsignore
2DiBiMIS, University of Palermo, and CNR Institute of Biomedicine and Molecular Immunology (IBIM), Palermo, Italy
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Simon Herkenrath
1Institute of Pneumology at the University of Cologne, Bethanien Hospital, Clinic for Pneumology and Allergology, Centre of Sleep Medicine and Respiratory Care, Solingen, Germany
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Tables

  • TABLE 1

    Overview of main findings from studies investigating effects on cardiovascular outcome of continuous positive airway pressure (CPAP) treatment in obstructive sleep apnoea (OSA) patients

    First author [ref.]Population characteristicsDefinition and measurement of OSADesign/total size for primary analysisGroups/interventions(Primary) outcomeMain result
    Mil [97]
    • CAD

    • ≥70% stenosis of a major carotid artery

    • OSA (exclusion of predominant CSA/CSR not reported)

    • AHI ≥15 events·h−1

    • In-lab PSG

    • Symptoms consistent with OSA

    • Prospective, long-term observational cohort study, n=54

    • Treated OSA, n=25 (nasal CPAP n=21, surgery n=4); median follow-up 86 months

    • Untreated OSA, n=29; median follow-up 90 months

    • MACCE (cardiovascular mortality, ACS, HF-related hospitalisation, repeat revascularisation)

    • HR 0.24 (0.09–0.62), treated versus untreated

    Stradling [103]
    • OSA

    • >1 year on CPAP

    • Average compliance >4 h·night−1

    • AHI <10 events·h−1 on CPAP

    • CSR excluded

    • ODI >20 events·h−1 (4%)

    • Oximetry during 4 nights off CPAP

    • Previous OSA diagnosis with ODI >20 events·h−1

    • Prospective, short-term, RCT, n=59

    • CPAP continuation, n=30

    • Sham CPAP, n=29

    • Duration 2 weeks

    • Blood markers of oxidative stress (MDA, lipid hydroperoxides, total anti-oxidant capacity, superoxide generation from mononuclear cells)

    • Urinary F2-isoprostane

    • Superoxide dismutase as a marker of hypoxic preconditioning

    • No significant change of blood markers of oxidative stress

    • Urinary F2-isoprostane fell significantly by ∼30%

    • Superoxide dismutase increased similarly

    Thunström [102]
    • CAD

    • OSA

    • Non-sleepy (ESS <10)

    • Predominantly central apnoeas with CSR excluded

    • AHI >15 events·h−1

    • Home-based PG

    • Prospective, long-term RCT

    • RCT arm of RICCADSA trial, n=220

    • CPAP, n=115

    • No CPAP, n=105

    • Follow-up 1 year

    • Change in circulating levels of inflammatory biomarkers from baseline to 1 year

    • Inflammatory biomarkers did not change significantly over time, except for IL-6 levels, which reduced to the same extent in the CPAP and no-CPAP groups

    Peker [101]
    • CAD

    • OSA/no OSA

    • Sleepy (ESS ≥10)

    • Predominantly central apnoeas with CSR excluded

    • AHI >15 events·h−1 (no OSA: AHI <5 events·h−1)

    • In-lab PSG

    • Prospective, long-term observational cohort study

    • Observational arm of RICCADSA trial, n=267

    • OSA with CPAP, n=155

    • No OSA, n=112

    • Median follow-up 57 months

    • MACCE (repeat revascularisation, MI, stroke and cardiovascular mortality)

    • Adjusted HR 0.96 (0.40–2.31), OSA with CPAP versus no OSA

    Peker [100]
    • CAD

    • OSA

    • Non-sleepy (ESS <10)

    • Predominantly central apnoeas with CSR excluded

    • AHI >15 events·h−1

    • Home-based PG

    • Prospective, long-term RCT

    • RCT arm of RICCADSA trial, n=244

    • CPAP, n=122

    • No CPAP, n=122

    • Median follow-up 57 months

    • MACCE (repeat revascularisation, MI, stroke and cardiovascular mortality)

    • Adjusted HR 0.62 (0.34–1.13), CPAP versus no CPAP

    Lin [99]
    • MI

    • OSA

    • Including unspecified sleep apnoea

    • Sleep apnoea as defined by ICD-9-CM 780.51, 780.53, 780.57, 327.23

    • Partly validated against PSG

    • Prospective, long-term observational cohort study, n=207

    • Sleep apnoea diagnosis before MI: with CPAP, n=26; without CPAP, n=74

    • Sleep apnoea diagnosis after MI: with CPAP, n=33; without CPAP, n=60

    • Median follow-up 4.2 years

    • MACCE (repeat MI, repeat revascularisation, hospitalisation for IHD, or stroke)

    • Sleep apnoea diagnosis before MI: adjusted HR 0.79 (0.55–1.12), no CPAP versus CPAP

    • Sleep apnoea diagnosis after MI: adjusted HR 1.48 (1.01–2.19), no CPAP versus CPAP

    Lewis [98]
    • CAD or ≥3 CAD risk factors

    • OSA

    • ESS ≤15

    • Predominant CSA excluded

    • HF excluded

    • AHI ≥15 events·h−1 (max. 50 events·h−1)

    • Home-based sleep study

    • Prospective, short-term, RCT, n=318

    • CPAP, n=106

    • Nocturnal supplemental oxygen, n=106

    • Healthy lifestyle education, n=106

    • Duration 12 weeks

    • HRQoL (SF-36)

    • Depression (PHQ-9)

    • CPAP improved vitality and mental status (SF-36) with greater improvement with higher levels of sleepiness (ESS ≥12)

    • CPAP gave greater improvement in PHQ-9 scores compared with healthy lifestyle education

    McEvoy [92]
    • CAD (51%) or cerebrovascular disease (49%)

    • OSA

    • ESS ≤15

    • NYHA III–IV HF excluded

    • CSR excluded

    • ODI (4%) ≥12 events·h−1

    • Home-based oximetry and nasal pressure

    • Prospective, long-term RCT, n=2687

    • CPAP plus standard of care, n=1346

    • Standard of care, n=1341

    • Mean follow-up 3.7 years

    • MACCE (death from cardiovascular causes, MI, stroke, or hospitalisation for unstable angina, HF, or transient ischaemic attack)

    • HR 1.10 (0.91–1.32)

    • In CPAP-adherent subgroup, HR 0.80 (0.60–1.07), n=561

    • CPAP significantly reduced snoring and daytime sleepiness and improved HRQoL and mood

    Buchner [93]
    • OSA

    • 23.6% of patients with CAD

    • Predominant CSA, CSR, hypoventilation syndromes or PLM excluded

    • AHI ≥5 events·h−1

    • In-lab PSG

    • Prospective, long-term observational cohort study, n=449

    • Treated OSA, n=364 (CPAP n=296, BiPAP n=48, MAD n=20)

    • Untreated OSA, n=85

    • Median follow-up 72 months

    • MACCE (death from MI or stroke, MI, stroke, and acute coronary syndrome requiring revascularisation procedures)

    • Adjusted HR 0.36 (0.21–0.62)

    Weaver [95]
    • OSA

    • Age max. 60 years

    • HF excluded

    • “Other sleep disorders” excluded

    • AHI ≥15 events·h−1

    • In-lab PSG

    • Prospective, short-term, observational, “quasi-experimental” study, n=149

    • ESS, MSLT, FOSQ normalised on therapy (n=70/106, 30/85, 68/120)

    • ESS, MSLT, FOSQ not normalised on therapy (n=36/106, 55/85, 52/120)

    • ESS

    • MSLT

    • FOSQ

    • Those who normalised on therapy used CPAP on average 1.1 (0.2–2.0), 1.1 (0.2–2.1), and 1.0 (0.2–1.8) h·night−1 more than those who did not, for the ESS, MSLT and FOSQ, respectively

    Marin [94]
    • OSA

    • Men only

    • AHI of different severity levels

    • In-lab PSG

    • Prospective, long-term, observational cohort study, n=1651

    • Healthy controls, n=264

    • Simple snorers, n=377

    • Untreated mild-to-moderate OSA, n=403

    • Untreated severe OSA, n=235

    • OSA plus CPAP, n=372

    • Mean follow-up 10 years

    • MACCE, fatal (MI, stroke)

    • MACCE, non-fatal (MI, stroke, CABG, PTCA)

    Incidence per 100 person-years of fatal and non-fatal MACCE, respectively:
    • Higher in untreated severe OSA: 1.06 and 2.13

    • Untreated mild-to-moderate OSA: 0.55, p=0.02, and 0.89, p<0.0001

    • Simple snorers: 0.34, p=0.0006, and 0.58, p<0.0001

    • OSA plus CPAP: 0.35, p=0.0008, and 0.64, p<0.0001

    • Healthy controls: 0.3, p=0.0012, and 0.45, p<0.0001

    • Adjusted HR for untreated severe OSA: fatal MACCE 2.87 (1.17–7.51) and non-fatal MACCE 3.17 (1.12–7.51) versus healthy controls

    CAD: coronary artery disease; CSA: central sleep apnoea; CSR: Cheyne–Stokes respiration; AHI: apnoea–hypopnoea index; PSG: polysomnography; MACCE: major adverse cardiac and cerebrovascular event; ACS: acute coronary syndrome; HF: heart failure; ODI: oxygen desaturation index; RCT: randomised controlled trial; MDA: malondialdehyde; ESS: Epworth Sleepiness Scale; PG: polygraphy; IL: interleukin; MI: myocardial infarction; ICD-9-CM: International Classification of Diseases, 9th Revision, Clinical Modification; IHD: ischaemic heart disease; HRQoL: health-related quality of life; SF-36: 36-item Short-Form Health Survey; PHQ-9: Patient Health Questionnaire-9; NYHA: New York Heart Association; PLM: periodic limb movements; BiPAP: bilevel positive airway pressure; MAD: mandibular advancement device; MSLT: multiple sleep latency test; FOSQ: Functional Outcomes of Sleep Questionnaire; CABG: coronary artery bypass graft surgery; PTCA: percutaneous transluminal coronary angioplasty.

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    Obstructive sleep apnoea in acute coronary syndrome
    Winfried Randerath, Maria R. Bonsignore, Simon Herkenrath
    European Respiratory Review Sep 2019, 28 (153) 180114; DOI: 10.1183/16000617.0114-2018

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    Obstructive sleep apnoea in acute coronary syndrome
    Winfried Randerath, Maria R. Bonsignore, Simon Herkenrath
    European Respiratory Review Sep 2019, 28 (153) 180114; DOI: 10.1183/16000617.0114-2018
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    • Article
      • Abstract
      • Abstract
      • Coronary artery disease and the pathogenesis of acute coronary syndrome
      • Epidemiology, symptoms and consequences of OSA
      • OSA and ACS: associations, sex differences and phenotyping
      • Prognostic relevance of OSA in ACS/AMI
      • Diagnosis of sleep disturbances, risk factors, predictors and biomarkers for poor ACS outcome
      • Treatment effect
      • Adherence
      • Conclusions
      • Footnotes
      • References
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    Subjects

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    Series

    • New antibiotics for Gram-negative pneumonia
    • Severe community-acquired pneumonia
    • Pulmonary aspergillosis: diagnosis and treatment
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    Sleep disordered breathing

    • Non-sleepy OSA: to treat or not to treat?
    • Sex differences in OSA
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