Outcomes of endovascular therapy for Stanford type B aortic dissection in patients with sleep apnea syndrome.

OBJECTIVE: This study aimed to determine the influences of varying severity of sleep apnea syndrome (SAS) on the outcomes after thoracic endovascular aorta repair (TEVAR) in patients with Stanford type B aortic dissection (TBAD). METHODS: This observational study focused on individuals with TBAD plus SAS who received TEVAR between January 2018 and December 2022. Patients were divided into groups according to the results of the portable sleep-breathing monitoring systems: mild SAS (MSAS) and moderate-to-severe SAS (MSSAS). Clinical profiles were collected and analyzed. RESULTS: A total of 121 cases with TBAD plus SAS who underwent TEVAR were enrolled in this study. Two groups were formed by stratifying these cases: MSAS (74 cases) and MSSAS (47 cases). The MSSAS cases were found to be older relative to MSAS cases (51.7 ± 8.3 years vs 57.1 ± 12.8 years; P = .012) and had a higher body mass index (BMI; 25.7 ± 2.3 kg/m2vs 27.0 ± 2.3 kg/m2; P = .038). The investigation did not find any appreciable differences between the MSAS and MSSAS groups in terms of complications (endoleak, P = .403; stent-induced new entry, P >.999; and stent displacement: P >.999). However, the MSSAS group exhibited a significantly higher overall mortality rate compared with the MSAS group (log-rank P = .027). The tendency continued when examining cases with Marfan syndrome combined with MSSAS, where the overall mortality rate was significantly greater compared with Marfan syndrome cases with MSAS (log-rank P = .037). The absence of a significant difference was noteworthy in the freedom from reintervention between the MSAS and MSSAS groups (log-rank P = .278). The overall mortality rate was significantly higher in MSSAS group even after adjusting for varying potential confounders in the multivariate cox regression analysis (hazard ratio [HR], 1.875; 95% confidence interval [CI], 1.238-2.586; P = .012). A markedly higher rate of distal stent dilation in the MSSAS group was also observed compared with the MSAS group (HR, 2.5 mm/year [95% CI, 2-3 mm/year] vs HR, 4 mm/year [95% CI, 2.0-5.5 mm/year]; P = .029). CONCLUSIONS: MSSAS is associated with a significantly higher risk of overall mortality and dilation rate of the distal stent after TEVAR for TBAD patients. Hence, aggressive efforts to reverse the severity of SAS in time in these individuals seem to be necessary.

Age modifies the association between severe sleep apnea and all-cause mortality.

PURPOSE: While sleep apnea (SA) gets more prevalent with advancing age, the impact of age on the association between SA and health outcomes is not well known. We assessed the association between the severity of SA and all-cause mortality in different age groups using large longitudinal data. METHOD: We applied a Natural Language Processing pipeline to extract the apnea-hypopnea index (AHI) from the physicians' interpretation of sleep studies performed at the Veteran Health Administration (FY 1999-2022). We categorized the participants as no SA (n-SA, AHI< 5) and severe SA (s-SA, AHI≥30). We grouped the cohort based on age: Young≤40; Middle-aged:40-65; and Older adults≥65; and calculated the odds ratio (aOR) of mortality adjusted for age, sex, race, ethnicity, BMI, and Charlson-Comorbidity Index (CCI) using n-SA as the reference. RESULTS: We identified 146,148 participants (age 52.23 ± 15.02; BMI 32.11 ± 6.05; male 86.7 %; White 66 %). Prevalence of s-SA increased with age. All-cause mortality was lower in s-SA compared to n-SA in the entire cohort (aOR,0.56; 95%CI: 0.54,0.58). Comparing s-SA to n-SA, the all-cause mortality rates (Young 1.86 % vs 1.49 %; Middle-aged 12.07 % vs 13.34 %; and Older adults 26.35 % vs 40.18 %) and the aOR diminished as the age increased (Young: 1.11, 95%CI: 0.93-1.32; Middle-aged: 0.64, 95%CI: 0.61-0.67; and Older adults: 0.44, 95%CI: 0.41-0.46). CONCLUSION: The prevalence of severe SA increased while the odds of all-cause mortality compared to n-SA diminished with age. SA may exert less harmful effects on the aged population. A causality analysis is warranted to assess the relationship between SA, aging, and all-cause mortality.

Severity of sleep apnea as a prognostic factor for mortality in patients with multiple system atrophy.

BACKGROUND: We determined whether the severity of sleep apnea increases the risk of mortality in patients with multiple system atrophy (MSA) with and without stridor. MethodsThis retrospective study included patients who underwent polysomnography within one year after diagnosis of probable MSA. Stridor, sleep apnea, and arousal from sleep were determined using full-night polysomnography. Disease severity was measured using the Unified MSA Rating Scale (UMSARS). Survival data were collected and analyzed using Cox regression analysis. RESULTS: Sixty-four patients with MSA were included. During a median follow-up of 34.5 months, 49 (76.6 %) patients died. Stridor was present in 56.3 % of patients. Patients with stridor had more severe sleep apnea and shorter sleep time than those without, but the hazard ratio (HR) for death did not differ between patients with and without stridor. Among patients without stridor, apnea-hypopnea index ≥30/h (HR, 6.850; 95 % confidence interval [CI], 1.983-23.664; p = 0.002) and a score of UMSARS I + II (HR, 1.080; 95 % CI, 1.040-1.121; p < 0.001) were independently associated with death. In contrast, among patients with stridor, frequent arousals from sleep (HR, 0.254; 95 % CI, 0.089-0.729; p = 0.011) were a significant factor associated with longer survival, while MSA-cerebellar type tended to be associated with poor survival (HR, 2.195; 95 % CI, 0.941-5.120; p = 0.069). CONCLUSION: The severity of sleep apnea might be a significant predictor of shorter survival in MSA patients without stridor, whereas frequent arousals from sleep might be a significant predictor for longer survival in MSA patients with stridor.

Association of Patient Characteristics With Postoperative Mortality in Children Undergoing Tonsillectomy in 5 US States.

Importance: The rate of postoperative death in children undergoing tonsillectomy is uncertain. Mortality rates are not separately available for children at increased risk of complications, including young children (aged <3 y) and those with sleep-disordered breathing or complex chronic conditions. Objective: To estimate postoperative mortality following tonsillectomy in US children, both overall and in relation to recognized risk factors for complications. Design, Setting, and Participants: Retrospective cohort study based on longitudinal analysis of linked records in state ambulatory surgery, inpatient, and emergency department discharge data sets distributed by the Healthcare Cost and Utilization Project for 5 states covering 2005 to 2017. Participants included 504 262 persons younger than 21 years for whom discharge records were available to link outpatient or inpatient tonsillectomy with at least 90 days of follow-up. Exposures: Tonsillectomy with or without adenoidectomy. Main Outcome and Measures: Postoperative death within 30 days or during a surgical stay lasting more than 30 days. Modified Poisson regression with sample weighting was used to estimate postoperative mortality per 100 000 operations, both overall and in relation to age group, sleep-disordered breathing, and complex chronic conditions. Results: The 504 262 children in the cohort underwent a total of 505 182 tonsillectomies (median [IQR] patient age, 7 [4-12] years; 50.6% females), of which 10.1% were performed in young children, 28.9% in those with sleep-disordered breathing, and 2.8% in those with complex chronic conditions. There were 36 linked postoperative deaths, which occurred a median (IQR) of 4.5 (2-20.5) days after surgical admission, and most of which (19/36 [53%]) occurred after surgical discharge. The unadjusted mortality rate was 7.04 (95% CI, 4.97-9.98) deaths per 100 000 operations. In multivariable models, neither age younger than 3 years nor sleep-disordered breathing was significantly associated with mortality, but children with complex chronic conditions had significantly higher mortality (16 deaths/14 299 operations) than children without these conditions (20 deaths/490 883 operations) (117.22 vs 3.87 deaths per 100 000 operations; adjusted rate difference, 113.55 [95% CI, 51.45-175.64] deaths per 100 000 operations; adjusted rate ratio, 29.39 [95% CI, 13.37-64.62]). Children with complex chronic conditions accounted for 2.8% of tonsillectomies but 44% of postoperative deaths. Most deaths associated with complex chronic conditions occurred in children with neurologic/neuromuscular or congenital/genetic disorders. Conclusions and Relevance: Among children undergoing tonsillectomy, the rate of postoperative death was 7 per 100 000 operations overall and 117 per 100 000 operations among children with complex chronic conditions. These findings may inform decision-making for pediatric tonsillectomy.

Markers of ventricular repolarization and overall mortality in sleep disordered breathing.

INTRODUCTION: Variability and prolongation of ventricular repolarization - measured by changes in QT interval and QT variability are independently associated with ventricular arrhythmias, sudden death, and mortality but such studies did not examine the role of sleep-disordered breathing. We aimed to determine whether sleep-disordered breathing moderated the association between measures of ventricular repolarization and overall mortality. METHODS: Eight hundred participants were randomly selected from each of the following four groups in the Sleep Heart Health Study: mild, moderate, severe or no sleep disordered breathing (n = 200 each). Overnight electrocardiograms were analyzed for QTc duration and QT variability (standard deviation of QT intervals, normalized QT interval variance and the short-term interval beat-to-beat QT variability). Cox proportional hazards penalized regression modeling was used to identify predictors of mortality. RESULTS: Eight hundred of 5600 participants were randomly selected. The participants (68 ± 10 years; 56.8% male) were followed for an average of 8.2 years during which time 222 (28.4%) died. QTc, SDQT, and QTVN were associated with the presence of SDB (p = 0.002, p = 0.014, and p = 0.024, respectively). After adjusting for covariates, the presence of sleep-disordered breathing did not moderate the association between QTc length, QT variability and mortality (p > 0.05). CONCLUSION: Sleep-disordered breathing was associated with some measures of ventricular repolarization. However, sleep-disordered breathing was not an effect modifier for the relationship between QTc and QT variability and mortality.

Sleep Disordered Breathing and Mortality in Patients With Hypertrophic Obstructive Cardiomyopathy Undergoing Septal Myectomy.

OBJECTIVE: To determine the impact of sleep-disordered breathing (SDB) on survival in patients with hypertrophic cardiomyopathy (HCM) following septal myectomy. PATIENTS AND METHODS: Patients with obstructive HCM undergoing septal myectomy from 2007 to 2016 were reviewed. Those who had an overnight oximetry test within 6 months before myectomy were included in analysis. Oxygen desaturation index was examined continuously and also categorically (SDB [>5/h] and severe SDB [>15/h]). RESULTS: A total of 619 of 1500 patients undergoing septal myectomy had overnight oximetry tests. Sleep-disordered breathing (oxygen desaturation index >5/h) was identified in 338 (54.6%) patients, and among those patients, 117 (18.9%) were classified as severe. Patients with SDB were older, had greater body mass index and body surface area, were more likely to have arterial hypertension and atrial fibrillation, and had an increased E/e' ratio on Doppler echocardiography. Notably, there was no difference in preoperative resting left ventricular outflow tract pressure gradient between patients with SDB and those with normal overnight oximetry (55 (interquartile range: 25 to 86) mm Hg versus 52 (interquartile range: 21 to 85) mm Hg; P=.29). There was no difference in age-adjusted survival among patients with normal oximetry compared with those with mild SDB (hazard ratio: 0.98; 95% CI: 0.45 to 2.17), and severe SDB (hazard ratio: 1.06, 95% CI 0.42 - 2.71). CONCLUSION: Sleep-disordered breathing is present in more than half of patients with obstructive HCM in whom septal myectomy is indicated, and is mainly associated with aging, overweight, and male sex. However, SDB does not alter survival following septal myectomy.

Morbidity and mortality reduction associated with polysomnography testing in idiopathic pulmonary fibrosis: a population-based cohort study.

BACKGROUND: It is not well-known if diagnosing and treating sleep breathing disorders among individuals with idiopathic pulmonary fibrosis (IPF) improves health outcomes. We evaluated the association between receipt of laboratory-based polysomnography (which is the first step in the diagnosis and treatment of sleep breathing disorders in Ontario, Canada) and respiratory-related hospitalization and all-cause mortality among individuals with IPF. METHODS: We used a retrospective, population-based, cohort study design, analyzing health administrative data from Ontario, Canada, from 2007 to 2019. Individuals with IPF were identified using an algorithm based on health administrative codes previously developed by IPF experts. Propensity score matching was used to account for potential differences in 41 relevant covariates between individuals that underwent polysomnography (exposed) and individuals that did not undergo polysomnography (controls), in order minimize potential confounding. Respiratory-related hospitalization and all-cause mortality were evaluated up to 12 months after the index date. RESULTS: Out of 5044 individuals with IPF identified, 201 (4.0%) received polysomnography, and 189 (94.0%) were matched to an equal number of controls. Compared to controls, exposed individuals had significantly reduced rates of respiratory-related hospitalization (hazard ratio [HR] 0.43, 95% confidence interval [CI] 0.24-0.75), p = 0.003) and all-cause mortality (HR 0.49, 95% CI 0.30-0.80), p = 0.004). Significantly reduced rate of respiratory-related hospitalization (but not all-cause mortality) was also observed among those with > = 1 respiratory-related hospitalization (HR 0.38, 95% CI 0.15-0.99) and systemic corticosteroid receipt (HR 0.37, 95% CI 0.19-0.94) in the year prior to the index date, which reflect sicker subgroups of persons. CONCLUSIONS: Undergoing polysomnography was associated with significantly improved clinically-important health outcomes among individuals with IPF, highlighting the potential importance of incorporating this testing in IPF disease management.

Risk stratification after acute myocardial infarction by amplitude-frequency mapping of cyclic variation of heart rate.

BACKGROUND: Blunted cyclic variation of heart rate (CVHR), measured as a decrease in CVHR amplitude (Acv), predicts mortality risk after acute myocardial infarction (AMI). However, Acv also can be reduced in mild sleep apnea with mild O2 desaturation. We investigated whether Acv's predictive power for post-AMI mortality could be improved by considering the effect of sleep apnea severity. METHODS: In 24-hr ECG in 265,291 participants of the Allostatic State Mapping by Ambulatory ECG Repository project, sleep apnea severity was estimated by the frequency of CVHR (Fcv) measured by an automated algorithm for auto-correlated wave detection by adaptive threshold (ACAT). The distribution of Acv on the Acv-Fcv relation map was modeled by percentile regression, and a function converting Acv into percentile value was developed. In the retrospective cohort of the Enhancing Recovery in Coronary Heart Disease (ENRICHD) study, consisting of 673 survivors and 44 non-survivors after AMI, the mortality predictive power of percentile Acv calculated by the function was compared with that of unadjusted Acv. RESULTS: Among the ALLSTAR ECG data, low Acv values appeared more likely when Fcv was low. The logistic regression analysis for mortality in the ENRICHD cohort showed c-statistics of 0.667 (SE, 0.041), 0.817 (0.035), and 0.843 (0.030) for Fcv, unadjusted Acv, and the percentile Acv, respectively. Compared with unadjusted Acv, the percentile Acv showed a significant net reclassification improvement of 0.90 (95% CI, 0.51-1.42). CONCLUSIONS: The predictive power of Acv for post-AMI mortality is improved by considering its relation to sleep apnea severity estimated by Fcv.

Prolonged Circulation Time Is Associated With Mortality Among Older Men With Sleep-Disordered Breathing.

BACKGROUND: Conventional metrics to evaluate sleep-disordered breathing (SDB) have many limitations, including their inability to identify subclinical markers of cardiovascular (CV) dysfunction. RESEARCH QUESTION: Does sleep study-derived circulation time (Ct) predict mortality, independent of CV risks and SDB severity? STUDY DESIGN AND METHODS: We derived average lung to finger Ct (LFCt) from sleep studies in older men enrolled in the multicenter Osteoporotic Fractures in Men (MrOS) Sleep study. LFCt was defined as the average time between end of scored respiratory events and nadir oxygen desaturations associated with those events. We calculated the hazard ratio (HRs) for the CV and all-cause mortality by LFCt quartiles, adjusting for the demographic characteristics, body habitus, baseline CV risk, and CV disease (CVD). Additional models included apnea-hypopnea index (AHI), time with oxygen saturation as measured by pulse oximetry (SpO2) < 90% (T90), and hypoxic burden. We also repeated analyses after excluding those with CVD at baseline. RESULTS: A total of 2,631 men (mean ± SD age, 76.4 ± 5.5 years) were included in this study. LFCt median (interquartile range) was 18 (15-22) s. During an average ± SD follow-up of 9.9 ± 3.5 years, 427 men (16%) and 1,205 men (46%) experienced CV death and all-cause death, respectively. In multivariate analysis, men in the fourth quartile of LFCt (22-52 s) had an HR of 1.36 (95% CI, 1.02-1.81) and 1.35 (95% CI, 1.14-1.60) for CV and all-cause mortality, respectively, when compared with men in the first quartile (4-15 s). The results were similar when additionally adjusting for AHI, T90, or hypoxic burden. Results were stronger among men with no history of CVD at baseline. INTERPRETATION: LFCt is associated with both CV and all-cause mortality in older men, independent of baseline CV burden and SDB metrics. LFCt may be a novel physiologic marker for subclinical CVD and adverse outcomes in patients with SDB.

The clinical impacts of sleep apnea on mortality and allograft function in kidney transplant patients: A meta-analysis.

BACKGROUND: Sleep apnea (SA) is common in patients with advanced chronic kidney disease. However, its prevalence and clinical significance in kidney transplant patients are unknown. OBJECTIVE: To demonstrate the clinical impacts of SA on kidney allograft and mortality from current evidence to date. MATERIALS AND METHODS: Ovid -MEDLINE, EMBASE, and the Cochrane Library were searched for eligible publications. Kidney transplant recipients aged ≥ 18 years with SA were included. The outcomes included overall mortality, graft failure, and graft loss. Graft loss was attributed by either 1) graft failure requiring renal replacement therapy (RRT)or 2) death. RESULTS: Four observational studies (n = 5,259) were included in the meta-analyses. The mean age was 49.6 ± 0.4 years. Most patients were male (58.3%) and white (82.1%). Up to 25.1% had diabetes, 15.2% had SA, and 36.8% had history of smoking. The mean body mass index was 26.9 ± 0.9 kg/m2. With the mean follow-up duration of 14.4 ± 4.2 years, the pooled adjusted odds ratios (ORs) for graft failure and mortality among kidney transplant patients with SA were 1.061 (95% CI, 0.851 - 1.322; I2 = 41.3%) and 1.044 (95% CI, 0.853 - 1.278; I2 = 0%), respectively. The pooled adjusted OR for graft loss was 0.837 (95% CI, 0.597 - 1.173; I2 = 0%). On subgroup analyses, the ORs for graft failure were similar after adjusted by study year, country, study design, sample size, ethnicity, and sex. No potential publication bias was detected. CONCLUSION: With 14-year follow-up, SA in kidney transplant patients was not associated with worsening clinical and allograft outcomes, such as graft loss, graft failure, and mortality. However, additional observational studies are needed to confirm this finding.

Chronic kidney disease and concomitant sleep apnea are associated with increased overall mortality: a meta-analysis.

PURPOSE: Sleep apnea (SA) is common in advanced chronic kidney disease (CKD) patients. However, the association between CKD with concomitant SA and overall mortality remains inconclusive. METHODS: Ovid MEDLINE, EMBASE, and the Cochrane Library were searched for eligible publications, including non-transplant CKD patients aged > 18 years with co-existing SA. CKD is defined by estimated glomerular filtration rate of < 60 mL/min/1.73 m2. RESULTS: Seven observational studies (n = 186,686) were included in the meta-analyses. 94.2% had end-stage kidney disease (ESKD) requiring hemodialysis (HD), 5.0% had ESKD requiring peritoneal dialysis (PD), and 0.8% had non-dialysis CKD. The mean age was 76.8 ± 2.2 years. Most patients were male (53.4%) and white (76.8%). Up to 39.3% had diabetes. The mean body mass index was 26.0 ± 0.6 kg/m2. Among patients with advanced CKD and SA, the pooled estimated odds ratios (OR) for overall mortality and cardiovascular events were 2.092 (95% CI, 1.594-2.744) and 1.020 (95% CI, 0.929-1.119), respectively, compared to patients with CKD alone. The OR was 2.145 (95% CI, 1.563-2.944) when studies with polysomnography-diagnosed SA were examined independently. No potential publication bias was detected. There were no significant differences in odds ratios for overall mortality, based on subgroup analyses. CONCLUSION: Co-existence between advanced CKD and SA is associated with increased overall mortality, but not cardiovascular (CV) events when compared with CKD alone. The analysis of CV events requires additional studies to confirm our findings. Moreover, clinical interventions aiming to prevent the progression of SA and CKD are encouraged.

Sleep-Disordered Breathing Is Associated With Recurrent Ischemic Stroke.

Background and Purpose- Limited data are available about the relationship between sleep-disordered breathing (SDB) and recurrent stroke and mortality, especially from population-based studies, large samples, or ethnically diverse populations. Methods- In the BASIC project (Brain Attack Surveillance in Corpus Christ), we identified patients with ischemic stroke (2010-2015). Subjects were offered screening for SDB with the ApneaLink Plus device, from which a respiratory event index (REI) score ≥10 defined SDB. Demographics and baseline characteristics were determined from chart review and interview. Recurrent ischemic stroke was identified through active and passive surveillance. Cause-specific proportional hazards models were used to assess the association between REI (modeled linearly) and ischemic stroke recurrence (as the event of interest), and all-cause poststroke mortality, adjusted for multiple potential confounders. Results- Among 842 subjects, the median age was 65 (interquartile range, 57-76), 47% were female, and 58% were Mexican American. The median REI score was 14 (interquartile range, 6-26); 63% had SDB. SDB was associated with male sex, Mexican American ethnicity, being insured, nonsmoking status, diabetes mellitus, hypertension, lower educational attainment, and higher body mass index. Among Mexican American and non-Hispanic whites, 85 (11%) ischemic recurrent strokes and 104 (13%) deaths occurred, with a median follow-up time of 591 days. In fully adjusted models, REI was associated with recurrent ischemic stroke (hazard ratio, 1.02 [hazard ratio for one-unit higher REI score, 95% CI, 1.01-1.03]), but not with mortality alone (hazard ratio, 1.00 [95% CI, 0.99-1.02]). Conclusions- Results from this large population-based study show that SDB is associated with recurrent ischemic stroke, but not mortality. SDB may therefore represent an important modifiable risk factor for poor stroke outcomes.

Apnea-Hypopnea Event Duration Predicts Mortality in Men and Women in the Sleep Heart Health Study.

RATIONALE: Obstructive sleep apnea is a risk factor for mortality, but its diagnostic metric-the apnea-hypopnea index-is a poor risk predictor. The apnea-hypopnea index does not capture the range of physiological variability within and between patients, such as degree of hypoxemia and sleep fragmentation, that reflect differences in pathophysiological contributions of airway collapsibility, chemoreceptive negative feedback loop gain, and arousal threshold. OBJECTIVES: To test whether respiratory event duration, a heritable sleep apnea trait reflective of arousal threshold, predicts all-cause mortality. METHODS: Mortality risk as a function of event duration was estimated by Cox proportional hazards in the Sleep Heart Health Study, a prospective community-based cohort. Gender-specific hazard ratios were also calculated. MEASUREMENTS AND MAIN RESULTS: Among 5,712 participants, 1,290 deaths occurred over 11 years of follow-up. After adjusting for demographic factors (mean age, 63 yr; 52% female), apnea-hypopnea index (mean, 13.8; SD, 15.0), smoking, and prevalent cardiometabolic disease, individuals with the shortest-duration events had a significant hazard ratio for all-cause mortality of 1.31 (95% confidence interval, 1.11-1.54). This relationship was observed in both men and women and was strongest in those with moderate sleep apnea (hazard ratio, 1.59; 95% confidence interval, 1.11-2.28). CONCLUSIONS: Short respiratory event duration, a marker for low arousal threshold, predicts mortality in men and women. Individuals with shorter respiratory events may be predisposed to increased ventilatory instability and/or have augmented autonomic nervous system responses that increase the likelihood of adverse health outcomes, underscoring the importance of assessing physiological variation in obstructive sleep apnea.

Nocturnal Hypoxemia, But Not Sleep Apnea, Is Associated With a Poor Prognosis in Patients With Pulmonary Arterial Hypertension.

BACKGROUND: Sleep apnea (SA) can cause repeated nocturnal arterial oxygen desaturation and result in acute increase in pulmonary arterial pressure (PAP). The presence of SA is associated with a poor prognosis in patients with chronic left-sided heart failure, but little is known for patients with pulmonary arterial hypertension (PAH). Methods and Results: We enrolled 151 patients with PAH (44±16 years old, male/female=37/114). They were all in the Nice Classification group 1 (idiopathic PAH/associated PAH=52/48%, mean PAP of 46±16 mmHg). They underwent right-heart catheterization and a sleep study with simplified polysomnography. Averaged percutaneous oxygen saturation (SpO2) during sleep was measured and an apnea-hypopnea index >5 was defined as SA. SA was noted in 58 patients (obstructive SA/central SA: 29/29). Over an average follow-up of 1,170±763 days, 32 patients died. By Kaplan-Meier analysis, there was no significant difference in deaths of patients with and without SA (χ2=2.82, P=0.093). On the other hand, the mortality in patients with lower averaged SpO2 was significantly higher than in those with higher averaged SpO2 (χ2=14.7, P<0.001) and that was the only independent variable related to death in multivariate Cox proportional hazards analysis. CONCLUSIONS: SA in patients with PAH was not associated with worse prognosis, unlike left ventricular heart failure, but nocturnal hypoxemia was related to poor prognosis.

Sleep-disordered breathing, neuroendocrine function, and clinical SUDEP risk in patients with epilepsy.

INTRODUCTION: Sudden unexpected death in epilepsy (SUDEP) is a major contributor to epilepsy-related mortality. It is associated with nocturnal seizures and centrally mediated postictal cardiorespiratory dysfunction (CRD), but mechanisms and contributors remain poorly understood. METHODS: We performed a prospective, cross-sectional, observational pilot study in the Columbia University Medical Center (CUMC) adult epilepsy monitoring unit (EMU) to explore relationships between periictal CRD, sleep-disordered breathing (SDB), neuroendocrine function, and clinical SUDEP risk. Thirty patients (twenty women, ten men) underwent video-electroencephalogram (EEG) with electrocardiogram (EKG) and digital pulse oximetry, inpatient or outpatient polysomnography (PSG), and comprehensive laboratory evaluation of sex steroid hormones. Sudden unexpected death in epilepsy risk was defined as Low (0-2) or High (≥3) using the revised SUDEP-7 Inventory. Sleep-disordered breathing was defined using standard criteria. Neuroendocrine dysfunction was defined as ≥1 laboratory abnormality. RESULTS: Cardiorespiratory dysfunction occurred more frequently in high-risk patients (60% vs. 27%, p = 0.018). Endocrine dysfunction was seen in 35% of patients, more in men (p = 0.018). Sleep-disordered breathing was found in 88% of fully scoreable PSGs. CONCLUSIONS: There was no significant relationship between CRD, SDB, and neuroendocrine status, though all PSGs in those with high SUDEP risk or neuroendocrine dysfunction revealed SDB. Larger studies are needed to further elucidate relationships between CRD, SDB, neuroendocrine factors, and SUDEP.

Timely diagnosis and treatment of sleep apnea reduce cardiovascular sequelae in patients with myocardial infarction.

BACKGROUND: The present study aimed to test if the temporal sequence between sleep apnea (SA) diagnosis and incident myocardial infarction (MI) was associated with the long-term mortality and cardiovascular event in a community-based cohort. METHODS: We retrieved data from 9,453 incident MI patients between Jan. 1st 2000 and Dec. 31st 2012 from the Taiwan National Health Insurance Research Database. The study subjects included 207 MI patients with SA (SA-MI), further stratified into 110 with pre-existing SA before MI (SA-bMI) and 96 diagnosed with SA after MI (SA-pMI). The median follow-up period was 4.2 years. Propensity-score-matched controls were selected from 9,246 non-SA MI patients (non-SA-MI). The association of SA and outcomes including all-cause mortality and major adverse cardiac and cerebrovascular events (MACCEs) were analyzed by a Cox proportional hazards model. RESULTS: The result showed that SA was not associated with mortality regardless of the timing of SA diagnosis. SA-pMI was associated with increased risk of MACCEs (Hazard ratio [HR]: 1.412, 95% confidence interval [CI]: 1.037~1.923, p = 0.029) including re-MI or revascularization and ischemic heart disease hospitalization. Such an association was most significant for SA diagnosed within one year after MI (HR: 2.029, 95% CI: 1.265~3.254, p = 0.003), which was not seen in patients treated with continuous positive airway pressure (CPAP). CONCLUSION: The temporal sequence and the time interval between SA diagnosis and incident MI was associated with the cardiovascular events after MI, especially within one year after MI. Early assessment for the presence of SA after incident MI and early CPAP intervention may reduce the risk of further adverse cardiovascular events.

Sleep-disordered breathing and electrocardiographic QRS-T angle: The MESA study.

INTRODUCTION: Sleep-disordered breathing (SDB) has been linked to sudden cardiac death (SCD) but the mechanism is unclear. Abnormal QRS-T angle, a novel electrocardiographic (ECG) marker of ventricular repolarization, has been linked to adverse cardiovascular outcomes including SCD. We hypothesized that individuals with SDB have more pronounced abnormality in QRS-T angle. METHODS: We performed a cross-sectional analysis from the Multi-Ethnic Study of Atherosclerosis (MESA) Exam Sleep ancillary study. We calculated the odds ratio (OR) of abnormal frontal and spatial QRS-T angle (defined as >sex-specific 95th percentile thresholds) related to the apnea-hypopnea index (AHI) using logistic regression, adjusting for demographics, body habitus, cardiovascular risks, and prevalent cardiovascular disease. Linear associations between AHI and frontal and spatial QRS-T angle, separately, were also examined using multiple regression models. RESULTS: A total of 1,804 participants (mean age 67.9 (±9.0) years, 55.3% women and 64.1% non-whites) were included in the study. Sleep-disordered breathing was common among participants (median AHI 8.6 events/hr IQR [3.2-19.5/hr]). Higher AHI was associated with the odds of abnormal frontal (≥81° in men and ≥79° in women) and spatial QRS-T angle (≥129.7° in men and ≥115.9° in women; OR [95%CI]: 1.25 [1.02-1.51], p = 0.03; 1.23 [1.01-1.50], p = 0.04 respectively per 1 SD [16.8 events/hr] increase in AHI). Similarly, linear associations were observed (frontal QRS-T angle: beta coefficient: 2.30° [0.92, 3.66], p = 0.001; spatial QRS-T angle: beta coefficient: 2.16° [0.67, 3.64], p = 0.005). CONCLUSION: In a racially/ethnically diverse community cohort, severity of SDB is associated with abnormal ventricular repolarization as measured by QRS-T angle.

The association of neck circumference with incident congestive heart failure and coronary heart disease mortality in a community-based population with or without sleep-disordered breathing.

BACKGROUND: Neck circumference (NC), representing upper body subcutaneous adipose tissue, may be correlated with increased risk of overweight/obesity, obstructive sleep apnoea, and metabolic and cardiovascular disease. However, the relationship between NC and the incidence of congestive heart failure (CHF) or mortality due to coronary heart disease (CHD) in a community-based population with and without sleep-disordered breathing (SDB) has not yet been clarified. METHODS: We performed a prospective study using the Sleep Heart Health Study (SHHS) cohort. Cox proportional hazards regression models were used to estimate the association of different levels of NC with CHF incidence or CHD mortality in 2234 individuals with SDB and 2199 without SDB, respectively. RESULTS: After adjusting for age, sex, and body mass index (BMI), NC was significantly associated with CHF when comparing the highest NC quartile group with the lowest (hazard ratio, HR, 2.265, 95% confidence interval, CI, 1.074-4.777) in the non-SDB population. This association diminished after further adjustment for other risk factors, but remained statistically significant, with an adjusted HR of 1.082 (95% CI 1.003-1.166) per unit increase in NC. Additionally, after adjustment for age, sex, and BMI, NC was also shown to be remarkably associated with CHD mortality (HR 1.141, 95% CI 1.014-1.282) per unit increase in NC in the non-SDB population but not in the SDB population. After adjustment for all the covariates, there was a significant association between NC and CHD death in those without SDB, with an adjusted HR of 1.134 (95% CI 1.001-1.284) per unit increase in NC. CONCLUSIONS: NC may correlate with CHF incidence and CHD mortality in population without SDB. NC measurement may help risk stratification for cardiovascular diseases. TRIAL REGISTRATION: NCT00005275 , January 1994.

Comparison of Stanford B Aortic Dissection Patients Who Received Thoracic Endovascular Aortic Repair Combined with or without Sleep Apnea Syndrome.

BACKGROUND: Patients with Stanford B aortic dissection (AD) are usually found to have sleep apnea syndrome (SAS). This condition always complicates the patients' respiration. In this study, we collected and analyzed data of patients' perioperative managements during thoracic endovascular aortic repair (TEVAR) for treating patients with Stanford B AD and SAS. Comparison has been made between the patients with SAS and those without SAS. METHODS: Between June 2013 and June 2014, the clinical data and outcomes of the Stanford B AD patients in the Department of Vascular Surgery in the Second Xiangya Hospital were retrospectively reviewed and studied. According to the result of polysomnography obtained by using a portable polysomnography monitor (Nox T3, Nox Medical Co. Iceland) in TEVAR candidates, patients have been stratified into SAS-positive and SAS-negative group. Comparison of various variables has been made between these 2 groups. RESULTS: One hundred thirty-four patients, with Stanford B AD and treated by TEVAR in our center, were enrolled in this study. Patients' mean age was 52.46 ± 10.84 years. Gender ratio is 114:20, including male 85.07% (114/134) and female 14.93% (20/134). TEVAR was performed in 71.64% (96/134) patients under general anesthesia and 38 patients under local anesthesia. The mean body mass index (BMI) was 23.5 ± 4.2, and the longest follow-up time was 46 months. The patients were stratified into SAS-positive group (n = 23) and SAS-negative group (n = 111). Compared with the patients in the SAS-negative group, those in the SAS-positive group were younger (54.36 ± 0.97 vs. 43.3 ± 1.84 P < 0.0001) but had higher BMI (25.48 ± 0.71 vs. 22.24 ± 0.23, P < 0.0001), with longer hospitalization time (25.52 ± 0.59 vs. 15.68 ± 0.27; P < 0.0001) and without significant differences in the intensive care unit (ICU) stay time (54.87 ± 12.57 vs. 40.27 ± 8.10; P = 0.3369). Furthermore, the complication rate of pulmonary infection (65.22% vs. 13.51%; P < 0.0001), respiratory failure (26.09% vs. 1.80%; P = 0.003), heart failure (26.09% vs. 3.60%; P = 0.0018), and renal failure (30.43% vs. 5.40%; P = 0.0016) are significantly different between SAS-positive and SAS-negative groups. According to the 46-month follow-up, the survival rate of the 2 groups had no significant differences (P = 0.0846). The SAS-negative group result showed that the survival time had no significant correlation with all the factors we explored, whereas the SAS-positive group result showed that the survival time is significantly correlated only with pulmonary infection/failure (r = 0.2798, 95% confidence interval 0.08741 to 0.452, P = 0.0038). CONCLUSIONS: Stanford B AD patients who had SAS are likely to have higher BMI. After treating with TEVAR, they usually have longer hospitalization and ICU stay time, as well as higher complication rate. However, there are no significant differences of the survival rate in midtime follow-up. The respiratory system evaluation should be considered carefully in those patients who have diagnosed as having SAS before and after TEVAR because those patients' survival situation may have correlation with their respiratory condition.