Discrimination Predicts Suboptimal Adherence to CPAP Treatment and Mediates Black-White Differences in Use.

BACKGROUND: Although racial and ethnic differences in CPAP adherence for OSA are widely established, no studies have examined the influence of perceived racial discrimination on CPAP usage, to our knowledge. RESEARCH QUESTION: (1) Do Black adults with OSA report experiencing greater amounts of discrimination than non-Hispanic White adults? (2) Is discrimination associated with poorer CPAP adherence over time, independent of self-identified race? (3) Does discrimination mediate the relationship between self-identified Black race and CPAP usage? STUDY DESIGN AND METHODS: In this prospective study, Black and non-Hispanic White adults with OSA initiating CPAP were enrolled from two sleep centers and completed questionnaires including sociodemographics, perceived discrimination, daytime sleepiness, insomnia symptoms, and depressive symptoms. Perceived discrimination was measured using the Everyday Discrimination Scale (EDS). Black and White group comparisons for baseline sociodemographic variables, sleep symptoms, and perceived discrimination were performed with Student t test or χ2/Fisher exact test, as appropriate. A linear regression model was completed with self-identified Black race and EDS total score as the primary independent variables of interest and mean daily CPAP usage at 30 and 90 days serving as the dependent outcomes. This regression modeling was repeated after adjusting for psychosocial variables known to be associated with CPAP usage. EDS total score was explored as a potential mediator of the association between self-identified Black race and mean daily CPAP adherence at 30 and 90 days. RESULTS: The sample for this analysis consisted of 78 participants (31% female, 38% Black) with a mean age of 57 ± 14 years. Sixty percent of the Black adults reported they experienced racial discrimination at least a few times each year. Relative to White adults, Black adults were also more likely to indicate more than one reason for discrimination (27% vs 4%, P = .003). Adjusting for discrimination, self-identified Black race was associated with 1.4 (95% CI, -2.3 to -0.4 h; P = .006) and 1.6 (95% CI, -2.6 to -0.6 h; P = .003) fewer hours of mean daily CPAP usage at 30 and 90 days, respectively. In the fully adjusted model, a 1-unit change in the total discrimination score (more discrimination) was associated with a 0.08-h (95% CI, 0.01-0.15 h; P = .029) and 0.08-h (95% CI, 0.01-0.16 h; P = .045) change in mean daily CPAP usage at 30 and 90 days, respectively. INTERPRETATION: Adults with OSA who encountered racial discrimination experienced greater decrement in CPAP usage than those who did not experience racial discrimination.

The Effect of Self-Reported Visual Impairment and Sleep on Cognitive Decline: Results of the Hispanic Community Health Study/Study of Latinos.

BACKGROUND: Visual impairment could worsen sleep/wake disorders and cognitive decline. OBJECTIVE: To examine interrelations among self-reported visual impairment, sleep, and cognitive decline in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) Miami-site. METHOD: HCHS/SOL Miami-site participants ages 45-74 years (n = 665) at Visit-1, who returned for cognitive test 7-years later (SOL-INCA). Participants completed the National Eye Institute Visual Functioning Questionnaire (NEI-VFQ), validated sleep questionnaires and test for obstructive sleep apnea (OSA) at Visit-1. We obtained verbal episodic learning and memory, verbal fluency, processing speed, and executive functioning at Visit-1 and at SOL-INCA. Processing speed/executive functioning were added to SOL-INCA. We examined global cognition and change using a regression-based reliable change index, adjusting for the time lapse between Visit-1 and SOL-INCA. We used regression models to test whether 1) persons with OSA, self-reported sleep duration, insomnia, and sleepiness have an increased risk for visual impairment, 2a) visual impairment is associated with worse cognitive function and/or decline, and 2b) sleep disorders attenuate these associations. RESULT: Sleepiness (ß= 0.04; p < 0.01) and insomnia (ß= 0.04; p < 0.001) were cross-sectionally associated with visual impairment, adjusting for sociodemographic characteristics, behavioral factors, acculturation, and health conditions. Visual impairment was associated with lower global cognitive function at Visit-1 (ß= -0.16; p < 0.001) and on average 7-years later (ß= -0.18; p < 0.001). Visual impairment was also associated with a change in verbal fluency (ß= -0.17; p < 0.01). OSA, self-reported sleep duration, insomnia, and sleepiness did not attenuate any of the associations. CONCLUSION: Self-reported visual impairment was independently associated with worse cognitive function and decline.

Within-night repeatability and long-term consistency of sleep apnea endotypes: the Multi-Ethnic Study of Atherosclerosis and Osteoporotic Fractures in Men Study.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is characterized by multiple "endotypic traits," including pharyngeal collapsibility, muscle compensation, loop gain, and arousal threshold. Here, we examined (1) within-night repeatability, (2) long-term consistency, and (3) influences of body position and sleep state, of endotypic traits estimated from in-home polysomnography in mild-to-severe OSA (apnea-hypopnea index, AHI > 5 events/h). METHODS: Within-night repeatability was assessed using Multi-Ethnic Study of Atherosclerosis (MESA): Traits derived separately from "odd" and "even" 30-min periods were correlated and regression (error vs. N windows available) provided a recommended amount of data for acceptable repeatability (Rthreshold = 0.7). Long-term consistency was assessed using the Osteoporotic Fractures in Men Study (MrOS) at two time points 6.5 ± 0.7 years apart, before and after accounting for across-year body position and sleep state differences. Within-night dependence of traits on position and state (MESA plus MrOS data) was estimated using bootstrapping. RESULTS: Within-night repeatability for traits ranged from R = 0.62-0.79 and improved to R = 0.69-0.83 when recommended amounts of data were available (20-35 7-min windows, available in 94%-98% of participants); repeatability was similar for collapsibility, loop gain, and arousal threshold (R = 0.79-0.83), but lower for compensation (R = 0.69). Long-term consistency was modest (R = 0.30-0.61) and improved (R = 0.36-0.63) after accounting for position and state differences. Position/state analysis revealed reduced loop gain in REM and reduced collapsibility in N3. CONCLUSIONS: Endotypic traits can be obtained with acceptable repeatability. Long-term consistency was modest but improved after accounting for position and state changes. These data support the use of endotypic assessments in large-scale epidemiological studies. CLINICAL TRIAL INFORMATION: The data used in the manuscript are from observational cohort studies and are not a part of the clinical trial.

Differences in Symptoms and Severity of Obstructive Sleep Apnea between Black and White Patients.

Rationale: Prior work suggests that Black patients have more severe obstructive sleep apnea (OSA) upon clinical presentation. However, the extent to which this may reflect differences in symptoms or other standard measures of OSA risk is unclear. Objectives: We assessed for racial disparities in OSA characteristics at time of initial clinical diagnosis. Methods: Data from 890 newly diagnosed patients with OSA at an urban academic sleep center were included in this analysis. All patients completed a standardized questionnaire on demographics and sleep-related symptoms and underwent laboratory polysomnography. Symptom severity at the time of evaluation was compared across race and sex. Results: Black men were underrepresented in the sleep lab, making up only 15.8% of the cohort and 31.3% of Black participants (P < 0.001). Despite this, Black men had the most severe OSA with a mean apnea hypopnea index of 52.4 ± 39.4 events/hour, compared with 39.0 ± 28.9 in White men, 33.4 ± 32.3 in Black women, and 26.2 ± 23.8 in White women (P < 0.001 for test of homogeneity). Black men also had the greatest burden of OSA symptoms with the highest mean Epworth Sleepiness Scale score (12.2 ± 5.9 versus 9.4 ± 5.2 in White men, 11.2 ± 5.9, in Black women, and 9.8 ± 5.6 in White women; P < 0.001). Compared with White men, Black men were 1.61 (95% CI [1.04-2.51]) times more likely to have witnessed apneas and 1.56 (95% CI [1.00-2.46]) times more likely to have drowsy driving at the time of OSA diagnosis. Conclusions: At the time of clinical diagnosis, Black men have greater disease severity, suggesting delay in diagnosis. Further, the greater burden of classic OSA symptoms suggests the delayed diagnosis of OSA in Black men is not due to atypical presentation. Further research is needed to identify why screening methods for OSA are not equitably implemented in the care of Black men.

A Validation Study of Four Different Cluster Analyses of OSA and the Incidence of Cardiovascular Mortality in a Hispanic Population.

BACKGROUND: Previous studies reported a strong association between sleepiness-related symptoms and comorbidities with poor cardiovascular outcomes among patients with moderate to severe OSA (msOSA). However, the validation of these associations in the Hispanic population from South America and the ability to predict incident cardiovascular disease remain unclear. RESEARCH QUESTION: In Hispanic patients with msOSA, are four different cluster analyses reproducible and able to predict incident cardiovascular mortality? STUDY DESIGN AND METHODS: Using the SantOSA cohort, we reproduced four cluster analyses (Sleep Heart Health Study [SHHS], Icelandic Sleep Apnea Cohort [ISAC], Sleep Apnea Cardiovascular Endpoints [SAVE], and The Institute de Recherche en Sante Respiratoire des Pays de la Loire [IRSR] cohorts) following a cluster analysis similar to each training dataset. The incidence of cardiovascular mortality was constructed using a Kaplan-Meier (log-rank) model, and Cox proportional hazards models were adjusted by confounders. RESULTS: Among 780 patients with msOSA in our cohort, two previous cluster analyses (SHHS and ISAC) were reproducible. The SAVE and IRSR cluster analyses were not reproducible in our sample. We identified the following subtypes for SHHS: "minimally symptomatic," "disturbed sleep," "moderate sleepiness," and "severe sleepiness." For ISAC, three different subtypes ("minimally symptomatic," "disturbed sleep," and "excessive sleepiness") were similar to the original dataset. Compared with "minimally symptomatic," we found a significant association between "excessive sleepiness" and cardiovascular mortality after 5 years of follow-up in SantOSA, hazard ratio (HR), 5.47; 95% CI, 1.74-8.29; P < .01; and HR, 3.23; 95% CI, 1.21-8.63; P = .02, using the SHHS and ISAC cluster analyses, respectively. INTERPRETATION: Among patients with msOSA, a symptom-based approach can validate different OSA patient subtypes, and those with excessive sleepiness have an increased risk of incident cardiovascular mortality in the Hispanic population from South America.

Association of Pediatric Obstructive Sleep Apnea With Elevated Blood Pressure and Orthostatic Hypertension in Adolescence.

Importance: Although pediatric guidelines have delineated updated thresholds for elevated blood pressure (eBP) in youth and adult guidelines have recognized obstructive sleep apnea (OSA) as an established risk factor for eBP, the relative association of pediatric OSA with adolescent eBP remains unexplored. Objective: To assess the association of pediatric OSA with eBP and its orthostatic reactivity in adolescence. Design, Setting, and Participants: At baseline of this population-based cohort study (Penn State Child Cohort) in 2000-2005, a random sample of 700 children aged 5 to 12 years from the general population was studied. A total of 421 participants (60.1%) were followed up in 2010-2013 after 7.4 years as adolescents (ages, 12-23 years). Data analyses were conducted from July 6 to October 29, 2020. Main Outcomes and Measures: Outcomes were the apnea-hypopnea index (AHI) score, ascertained via polysomnography conducted in a laboratory; eBP measured in the seated position identified using guideline-recommended pediatric criteria; orthostatic hyperreactivity identified with BP assessed in the supine and standing positions; and visceral adipose tissue assessed via dual-energy x-ray absorptiometry. Results: Among the 421 participants (mean [SD] age at follow-up, 16.5 [2.3] years), 227 (53.9%) were male and 92 (21.9%) were racial/ethnic minorities. A persistent AHI of 2 or more since childhood was longitudinally associated with adolescent eBP (odds ratio [OR], 2.9; 95% CI 1.1-7.5), while a remitted AHI of 2 or more was not (OR, 0.9; 95% CI 0.3-2.6). Adolescent OSA was associated with eBP in a dose-response manner; however, the association of an AHI of 2 to less than 5 among adolescents was nonsignificant (OR, 1.5; 95% CI, 0.9-2.6) and that of an AHI of 5 or more was approximately 2-fold (OR, 2.3; 95% CI, 1.1-4.9) after adjusting for visceral adipose tissue. An AHI of 5 or more (OR, 3.1; 95% CI, 1.2-8.5), but not between 2 and less than 5 (OR, 1.3; 95% CI, 0.6-3.0), was associated with orthostatic hyperreactivity among adolescents even after adjusting for visceral adipose tissue. Childhood OSA was not associated with adolescent eBP in female participants, while the risk of OSA and eBP was greater in male participants. Conclusions and Relevance: The results of this cohort study suggest that childhood OSA is associated with adolescent hypertension only if it persists during this developmental period. Visceral adiposity explains a large extent of, but not all, the risk of hypertension associated with adolescent OSA, which is greater in male individuals.

Primary aldosteronism and obstructive sleep apnea: A single-center cross-sectional study of the Japanese population.

ABSTRACT: A recent report demonstrated that the prevalence of obstructive sleep apnea (OSA) is 67.6% among Caucasian and Chinese patients with primary aldosteronism (PA). Moreover, the report showed a significant association between plasma aldosterone concentration (PAC) and the severity of OSA in Caucasian patients. However, no studies have examined the prevalence of OSA with PA or the association of its severity with PAC in the Japanese population. We retrospectively evaluated the prevalence and severity of OSA in 71 newly diagnosed Japanese patients with PA. Thirty-nine (55%) of the 71 patients were diagnosed with OSA, and 69% of PA patients with OSA reported snoring. No correlation was found between the respiratory event index (REI), snoring index, and PAC and plasma renin activity (PRA). In contrast, REI correlated significantly with body mass index (BMI), which was significantly correlated with PRA. In conclusion, although the severity of OSA did not correlate with PAC and PRA, there was a high prevalence of OSA among Japanese patients with PA. Moreover, the severity of OSA was strongly affected by BMI. Thus, the examination of OSA in patients with PA and the proper management of OSA might be important for the Japanese population.

C-reactive Protein and Risk of OSA in Four US Cohorts.

BACKGROUND: Individuals with OSA have elevated levels of inflammatory markers, but no prospective study has examined the role of inflammation in the development of OSA. RESEARCH QUESTION: Is C-reactive protein (CRP) prospectively associated with risk of developing OSA? STUDY DESIGN AND METHODS: We followed 1,882 women from the Nurses' Health Study (NHS) (2002-2012), 3,854 women from Nurses' Health Study II (NHSII) (1995-2013), 3,075 men from the Health Professionals Follow-up Study (HPFS) (1996-2012), and 1,919 women and men from the Multi-Ethnic Study of Atherosclerosis (MESA) (2000-2012) who did not have diagnosed OSA at baseline and for whom CRP levels were available. In NHS/NHSII/HPFS, physician-diagnosed OSA was self-reported. In MESA, at-home polysomnography was performed and OSA was identified as an apnea-hypopnea index ≥ 30. Logistic regression was used to estimate the OR for OSA risk according to baseline CRP level, adjusted for multiple inflammation-related factors. RESULTS: After multivariable adjustment not including BMI, the pooled OR for OSA risk per doubling of baseline CRP level was 1.24 (95% CI, 1.18-1.30). Additional adjustment for BMI substantially attenuated the association (pooled OR, 1.07; 95% CI, 1.01-1.12). The fully adjusted association was consistently stronger in individuals < 55 vs ≥ 55 years of age (P interaction = .01), in individuals with BMI < 25 vs ≥ 25 kg/m2 (P interaction = .02), and in pre- vs postmenopausal women (P interaction = .002). CRP was more strongly associated with risk of OSA associated with excessive daytime sleepiness, high airway collapsibility, and low arousal threshold (P heterogeneity < .05). INTERPRETATION: Higher CRP was prospectively associated with increased OSA risk, particularly among younger individuals, underweight/normal-weight individuals, or premenopausal women. The differential associations by OSA phenotype/endotype suggest possible mechanisms through which inflammation operates to modulate OSA risk. Given our reliance on a single CRP level measured a decade before OSA assessment, future studies with repeated CRP measurements are warranted to confirm these prospective associations.

Clinical characteristics of Asian patients with sleep apnea with low arousal threshold and sleep structure change with continuous positive airway pressure.

PURPOSE: Low respiratory arousal threshold (ArTH) has been observed to be prevalent in patients with obstructive sleep apnea (OSA), and is associated with poor adherence to continuous positive airway pressure (CPAP) treatment. This study aimed to examine the associations between low ArTH and clinical characteristics. The second aim was to examine sleep structure changes between diagnostic polysomnography (PSG) and CPAP titration studies. METHODS: PSG data for 3718 adults who had an apnea-hypopnea index (AHI) ≥ 5 were reviewed retrospectively, as well as 206 CPAP titration studies among these participants. Participants were dichotomized into low- and high-ArTH groups according to their PSG parameters. The associations between low ArTH and clinical characteristics were examined by multivariate logistic regressions. The sleep structure changes between PSG and CPAP titration studies were examined by repeated measures ANOVA. RESULTS: Fifty percent of patients with OSA had low ArTH. Compared with high-ArTH patients, low-ArTH patients were less obese and composed of a higher percentage of women. In logistic regression models, low ArTH was associated with bruxism and nocturia, but not with illnesses after adjusting for AHI and body mass index. Compared with diagnostic PSG studies, low-ArTH patients had significantly decreased stage changes and increased percentage of rapid eye movement sleep during CPAP titration studies. CONCLUSION: Low ArTH was prevalent in this large sample of patients with OSA. Arousal threshold was not associated with an increased risk of physical illnesses but was with certain clinical complaints. Low-ArTH patients benefited from CPAP titration study for improved sleep structure.

Association of Obstructive Sleep Apnea With Nighttime Blood Pressure in African Americans: The Jackson Heart Study.

BACKGROUND: Obstructive sleep apnea (OSA), nocturnal hypertension, and nondipping systolic blood pressure (BP) are each highly prevalent among African Americans. However, few data are available on the association between OSA and nighttime BP in this population. METHODS: We examined the association of OSA with nighttime BP among African Americans who completed 24-hour ambulatory BP monitoring (ABPM) at Exam 1 (2000-2004) of the Jackson Heart Study (JHS) and subsequently participated in the JHS Sleep Study (2012-2016). Type 3 home sleep apnea testing was used to assess OSA measures, including respiratory event index (REI4%) and percent sleep time <90% oxygen saturation (nocturnal hypoxemia). Nocturnal hypertension was defined as mean asleep systolic BP (SBP) ≥120 mm Hg or diastolic BP (DBP) ≥70 mm Hg. Multivariable linear regression models were fit to estimate the association between each OSA measure and nighttime SBP and DBP. RESULTS: Among 206 participants who completed ABPM and participated in the Jackson Heart Sleep Study, 50.5% had nocturnal hypertension and 26.2% had moderate to severe OSA (REI4% ≥15 events/hour). After multivariable adjustment, each SD (13.3 events/hour) increase in REI4% was associated with 1.75 mm Hg higher nighttime DBP (95% confidence interval (CI): 0.38, 3.11) and a prevalence ratio of 1.11 (95% CI: 1.00, 1.24) for nocturnal hypertension. Each SD (10.4%) increase in nocturnal hypoxemia was associated with a 1.91 mm Hg higher nighttime SBP (95% CI: 0.15, 3.66). CONCLUSIONS: Severity of OSA and nocturnal hypoxemia were associated with high nighttime BP in African American participants in the JHS.

Characteristics and Frequency of Children With Severe Obstructive Sleep Apnea Undergoing Elective Polysomnography.

OBJECTIVE: To determine the prevalence and demographics features of pediatric patients with severe obstructive sleep apnea (OSA) who would not undergo preoperative polysomnography (PSG) under current American Academy of Otolaryngology (AAO) guidelines. STUDY DESIGN: In this retrospective cohort study, we identified patients from the electronic medical record who underwent elective polysomnography for evaluation of sleep-disordered breathing between 2012 and 2018. SETTING: Urban tertiary safety net hospital. SUBJECTS AND METHODS: A total of 456 patients with a mean (SD) age of 5.7 (3.2) years (263 male, 193 female). Demographic factors (age, sex, race, language, insurance status) and clinical findings (symptom severity, tonsil size) were recorded. The data were analyzed by univariate analysis. RESULTS: Of 456 patients identified, 66 (14.5%) were found to have severe OSA. African American patients had 3.7 times the odds of severe OSA compared to white patients (95% CI, 1.2-10.8). Patients aged 2 to 3 years had 2.2 times the odds of severe OSA compared to patients aged 4 to 6 years (95% CI, 1.2-4.0). Sex, ethnicity, language, and insurance type were not significantly associated with severity of OSA. The presence of apneic episodes and tonsil size were not found to be statistically significant. CONCLUSION: Up to 14.5% of healthy pediatric patients with sleep-disordered breathing may have severe OSA; young age and African American race are statistically significant predictors. Clinical findings, such as tonsil size and symptom severity, were not found to be statistically significant predictors.

Obstructive sleep apnea in professional rugby league athletes: An exploratory study.

OBJECTIVES: To explore the prevalence of obstructive sleep apnea (OSA) within a professional rugby league team and determine associations of OSA with ethnicity, positional group, and physical characteristics. DESIGN: Observational prospective cohort study. METHODS: Twenty-two professional rugby league athletes underwent one night of home-based polysomnography with apnea-hypopnea index (AHI), rapid eye movement (REM)AHI, non-REMAHI and supineAHI determined to indicate OSA. Linear models were used to assess if playing position (back or forward) or ethnicity (European-Australian or Polynesian) influenced AHI, REMAHI, non-REMAHI and supineAHI. Models were also built to determine differences according to body composition. RESULTS: Seven athletes were classified with mild OSA (6 forwards and 1 back, 3 European-Australians, and 4 Polynesians) and three with moderate OSA (2 forwards and 1 back, 3 Polynesians). When considering ethnicity, differences were observed between Polynesians and European-Australians for REMAHI (ES=0.90, p=0.02). Increased body mass index (BMI) was associated with a moderate increase in AHI (r=0.38, p=0.04) and non-REMAHI (r=0.36, p=0.05), while higher skinfold thickness moderately related to a higher AHI (r=0.40, p=0.05) non-REMAHI (r=0.47, p=0.02), and supineAHI (r=0.41, p=0.04). CONCLUSIONS: This exploratory study found 10 cases of OSA. Polynesian athletes and athletes classified as forwards constituted the majority of reported cases, suggesting their susceptibility to OSA. Furthermore, the data suggests that athletes with greater BMI and skinfold thickness may be predisposed to OSA.

Defining Extreme Phenotypes of OSA Across International Sleep Centers.

BACKGROUND: Extreme phenotypes of OSA have not been systematically defined. RESEARCH QUESTION: This study developed objective definitions of extreme phenotypes of OSA by using a multivariate approach. The utility of these definitions for identifying characteristics that confer predisposition toward or protection against OSA is shown in a new prospective sample. STUDY DESIGN AND METHODS: In a large international sample, race-specific liability scores were calculated from a weighted logistic regression that included age, sex, and BMI. Extreme cases were defined as individuals with an apnea-hypopnea index (AHI) ≥ 30 events/hour but low likelihood of OSA based on age, sex, and BMI (liability scores > 90th percentile). Similarly, extreme controls were individuals with an AHI < 5 events/hour but high likelihood of OSA (liability scores < 10th percentile). Definitions were applied to a prospective sample from the Sleep Apnea Global Interdisciplinary Consortium, and differences in photography-based craniofacial and intraoral phenotypes were evaluated. RESULTS: This study included retrospective data from 81,338 individuals. A total of 4,168 extreme cases and 1,432 extreme controls were identified by using liability scores. Extreme cases were younger (43.1 ± 14.7 years), overweight (28.6 ± 6.8 kg/m2), and predominantly female (71.1%). Extreme controls were older (53.8 ± 14.1 years), obese (34.0 ± 8.1 kg/m2), and predominantly male (65.8%). These objective definitions identified 29 extreme cases and 87 extreme controls among 1,424 Sleep Apnea Global Interdisciplinary Consortium participants with photography-based phenotyping. Comparisons suggest that a greater cervicomental angle increases risk for OSA in the absence of clinical risk factors, and smaller facial widths are protective in the presence of clinical risk factors. INTERPRETATION: This objective definition can be applied in sleep centers throughout the world to consistently define OSA extreme phenotypes for future studies on genetic, anatomic, and physiologic pathways to OSA.

Association of Sleep Characteristics With Nocturnal Hypertension and Nondipping Blood Pressure in the CARDIA Study.

Background Sleep characteristics and disorders are associated with higher blood pressure (BP) when measured in the clinic setting. Methods and Results We tested whether self-reported sleep characteristics and likelihood of obstructive sleep apnea (OSA) were associated with nocturnal hypertension and nondipping systolic BP (SBP) among participants in the CARDIA (Coronary Artery Risk Development in Young Adults) study who completed 24-hour ambulatory BP monitoring during the year 30 examination. Likelihood of OSA was determined using the STOP-Bang questionnaire. Global sleep quality, habitual sleep duration, sleep efficiency, and midsleep time were obtained from the Pittsburgh Sleep Quality Index. Nocturnal hypertension was defined as mean asleep SBP ≥120 mm Hg or diastolic BP ≥70 mm Hg. Nondipping SBP was defined as a decline in awake-to-asleep SBP <10%. Among 702 participants, the prevalence of nocturnal hypertension and nondipping SBP was 41.3% and 32.5%, respectively. After multivariable adjustment including cardiovascular risk factors, the prevalence ratios (PRs) for nocturnal hypertension and nondipping SBP associated with high versus low likelihood of OSA were 1.32 (95% CI, 1.00-1.75) and 1.31 (95% CI, 1.02-1.68), respectively. The association between likelihood of OSA and nocturnal hypertension was stronger for white participants (PR: 2.09; 95% CI, 1.23-3.48) compared with black participants (PR: 1.11; 95% CI, 0.79-1.56). The PR for nondipping SBP associated with a 1-hour later midsleep time was 0.92 (95% CI, 0.85-0.99). Global sleep quality, habitual sleep duration, and sleep efficiency were not associated with either nocturnal hypertension or nondipping SBP. Conclusions These findings suggest that addressing OSA risk and sleep timing in a clinical trial may improve BP during sleep.

African ethnicity is associated with a higher prevalence of diabetes in obstructive sleep apnea patients: results of a retrospective analysis.

PURPOSE: Obstructive sleep apnea (OSA) syndrome is a well-recognized independent risk factor for cardiovascular disease and its prevalence is increasing. OSA symptomology, polysomnographic features, and comorbidities are heterogeneous among patients. Ethnicity is thought to influence OSA phenotypes, but extensive knowledge of OSA ethnic patterns is lacking. The primary aim of the present study was to compare comorbidities in Caucasian and African OSA. Secondary aims were to observe OSA symptomatology, polysomnographic characteristics, and CPAP adherence in these two ethnic groups. METHODS: In this retrospective study, 1717 patients suffering from moderate/severe OSA were included between 2013 and 2017. Data on demographics, symptomatology, comorbidities, polysomnographic characteristics, and CPAP adherence were collected. Data were analyzed to identify potential differences between Caucasians and Africans. RESULTS: Despite healthier lifestyles and lower BMI, a higher prevalence of diabetes but less cardiac comorbidities and dyslipidemia was observed in the African population. Younger African patients (< 56 years) suffered more from cognitive impairment than Caucasians and both younger and older Africans complained more of nighttime choking than Caucasians. In analysis of polysomnographic data, Africans had higher apnea-hypopnea index (AHI) in REM sleep, lower supine AHI, lower desaturation time, and lower periodic leg movements index. CONCLUSIONS: Compared with Caucasians, African OSA showed a particular comorbidity profile. There are younger patients who exhibit more diabetes but less cardiac comorbidities than the Caucasians. African diabetics should be more promptly referred for OSA testing. Moreover, as they suffer more often from choking and cognitive impairment, OSA treatment could positively impact their quality of life.

Obstructive sleep apnea risk and subclinical atherosclerosis in South Asians living in the United States.

OBJECTIVES: The objective of this study was to examine the association between high risk of obstructive sleep apnea (OSA) and subclinical atherosclerosis among South Asians in the United States. DESIGN: A secondary analysis of cross-sectional data. SETTING/PARTICIPANTS: A community-based cohort of 906 men and women participating in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study. MEASUREMENTS: The Berlin Questionnaire was used to screen for OSA risk. Coronary artery calcium (CAC), common carotid artery intima-media thickness (IMT), and internal carotid artery IMT were used as measures of subclinical atherosclerosis. RESULTS: The majority of participants (59%) with high OSA risk had CAC scores >0 compared with only 41% of participants with low OSA risk (P <.001). The high OSA risk group was older (P =.005), male (P =.04), had higher body mass index (P <.001) and had greater common carotid artery IMT (0.96 ± 0.27 mm) and internal carotid artery IMT (1.33 ± 0.42 mm) measurements. Snoring, sleep-disordered breathing (SDB), and high OSA risk were associated with subclinical atherosclerosis. However, only high OSA risk remained significant in multivariable models after controlling for demographic and clinical factors that included hypertension (HTN), obesity, diabetes, and dyslipidemia. CONCLUSIONS: High OSA risk, which includes overlapping comorbidities of HTN and obesity, was not associated with the time living in the US but was associated with subclinical atherosclerosis markers. These cardiovascular disease risk factors should include evaluation of the spectrum of SDB among all adults, including South Asian men and women.

Primary Aldosteronism and Obstructive Sleep Apnea: A Cross-Sectional Multi-Ethnic Study.

The association between primary aldosteronism (PA) and obstructive sleep apnea (OSA) has been a matter of debate. 2016 Endocrine Society guideline recommends screening for PA all hypertensive patients with OSA. We designed a multicenter, multiethnic, cross-sectional study to evaluate the prevalence of PA in patients with OSA and the prevalence of OSA in unselected patients with PA. Two hundred and three patients with OSA (102 whites and 101 Chinese) were screened for PA, and 207 patients with PA (104 whites, 100 Chinese, and 3 of African descent) were screened for OSA by cardiorespiratory polygraphy. Eighteen patients with OSA (8.9%) had PA (11.8% of white and 5.9% of Chinese ethnicity). In patients without other indications for PA screening, the prevalence of PA dropped to 1.5%. The prevalence of OSA in patients with PA was 67.6%, consistent in both white and Chinese patients. A correlation between aldosterone levels and apnea/hypopnea index was observed in white patients with PA (R2=0.225, P=0.016) but not in Chinese patients. Multinomial logistic regression confirmed a significant and independent association between plasma aldosterone levels and moderate to severe OSA diagnosis in white patients (odds ratio, 1.002; P=0.002). In conclusion, aldosterone levels may contribute to the severity of OSA in white patients with hyperaldosteronism, but patients with OSA are not at high risk of PA. Results of the present study challenge the current recommendation of the Endocrine Society guideline that all patients with OSA should be screened for PA, irrespective of the grade of hypertension.

A Look into Obstructive Sleep Apnea among Ethiopians.

BACKGROUND: Obstructive Sleep Apnea (OSA) is prevalent throughout the world. However, there are currently limited data concerning the prevalence of OSA in populations that originate from developing countries; the prevalence of OSA is expected to rise in these countries. OSA is poorly characterized amongst Ethiopians, and our study is the first to describe clinical characteristics of OSA among Ethiopians. METHODS: We conducted a retrospective study of primarily Ethiopian patients at an internal medicine clinic in Rockville, Maryland. All patients (n=24) were evaluated for daytime sleepiness using the Epworth Sleepiness Scale (ESS) and received physical examinations and polysomnograms (PSG) by either portable monitoring (Itamar WatchPAT 200 device) or in-lab. Statistical analyses were performed in R. RESULTS: Linear regression model of Body-Mass Index (BMI) and Apnea-Hypopnea Index (AHI) indicated that for every 1-unit increase in BMI, there was a 0.8657-unit increase in AHI (p<0.05). Pearson's correlation coefficient indicateda positive linear relationship between BMI and AHI (0.47) (p<0.05). Adjusted linear regression model for AHI and oxygen saturation indicated that for every 1-unit increase of AHI, there was a 0.8452-unit decrease in nocturnal oxygen saturation (p<0.05). Pearson's correlation coefficient did not demonstrate significance between AHI and oxygen desaturation (p=0.062). Patients received either continuous positive airway pressure (CPAP) (n=15) or oral appliance therapy (n=3). CONCLUSION: All patients who complied with therapy reported improved sleep quality, snoring resolution, and improved daytime alertness. Practitioners in developing countries should suspect OSA in the right clinical setting and offer diagnostic and therapeutic services when available.

Targeted Sequencing Analysis of the Leptin Receptor Gene Identifies Variants Associated with Obstructive Sleep Apnoea in Chinese Han Population.

PURPOSE: Obstructive sleep apnea (OSA) is a common sleep disorder that is influenced by various environmental and genetic factors. The potential associations of leptin and leptin receptor (LEPR) polymorphisms with OSA have been studied in different populations; however, the results remain inconclusive. The aim of this study was to examine the association between LEPR gene polymorphisms and OSA risk. METHODS: A total of 322 samples were used, including 226 OSA subjects and 96 controls. Targeted sequencing of the entire LEPR gene was performed in all subjects. Polysomnography was used to diagnose obstructive sleep apnea. The associations between variants and OSA were determined by multivariate regression analyses. RESULTS: Four single-nucleotide polymorphisms of LEPR were identified in all subjects. The genotype frequency of locus rs3790435 was significantly different between the OSA and control groups. Specifically, the variant genotype rs3790435 CC in LEPR was associated with a lower risk of OSA (OR 0.462, 95% CI 0.250-0.854, p = 0.014) in a recessive model after controlling for potential confounders. After BMI stratification, obese patients with this variant genotype were found to have a lower risk of developing OSA. Moreover, subjects with the rs3790435 CC genotype were found to have a statistically lower apnea-hypopnea index (AHI) and higher nadir oxygen saturation than the TT/CC genotypes without differences in plasma leptin levels. CONCLUSIONS: Our study identified a novel variant of LEPR in patients with OSA, and specifically found an association between rs3790435 polymorphisms and OSA risk in Chinese Han subjects.

Prevalence and Risk of Obstructive Sleep Apnea and Arterial Hypertension in the Adult Population in Poland: An Observational Subset of the International Prospective Urban Rural Epidemiology (PURE) Study.

Obstructive sleep apnea (OSA) is a common breathing disorder affecting millions of people worldwide. The disorder is connected with serious consequences including hypertension, myocardial infarction, arrhythmias, coronary disease, cardiac insufficiency, stroke, transient ischemic attack, and cognitive decline. Epidemiological data assessing the prevalence of OSA in different countries vary in methodology, size, and characteristics of population chosen and thus are hardly comparable. There are very few reports on the prevalence of OSA and on the diagnostic accuracy of sleep questionnaires available in Poland. In this report we present the analysis of the prevalence of, and risk factors for OSA in the Polish adult population consisting of 613 community-based subjects (227 men and 386 women). The study was based on the STOP-BANG questionnaire, a validated Screening Tool for OSA in primary care. It is a part of Polish subset of the Prospective Urban Rural Epidemiology (PURE) study, an ongoing population cohort study of individuals from urban and rural communities from 21 countries. We took into account age, gender, body mass index (BMI), and antihypertensive treatment. The findings are that over one half of the Polish population investigated had a moderate to high risk of OSA (66.5% of men and 60.1% of women). After the adjustments for age, gender, and BMI we noticed a dose-response relationship between arterial blood pressure behavior and OSA. The association was significant among women, but not men. Based on previous studies we can assume that one half of this high risk group would be further diagnosed for OSA. This study, the first large scale screening for OSA in Poland, shows a substantial, much higher than previously appreciated, prevalence of risk for OSA in the population at large.