Novel Sleep Phenotypic Profiles Associated With Incident Atrial Fibrillation in a Large Clinical Cohort.

BACKGROUND: While sleep disorders are implicated in atrial fibrillation (AF), the interplay of physiologic alterations and symptoms remains unclear. Sleep-based phenotypes can account for this complexity and translate to actionable approaches to identify at-risk patients and therapeutic interventions. OBJECTIVES: This study hypothesized discrete phenotypes of symptoms and polysomnography (PSG)-based data differ in relation to incident AF. METHODS: Data from the STARLIT (sleep Signals, Testing, And Reports LInked to patient Traits) registry on Cleveland Clinic patients (≥18 years of age) who underwent PSG from November 27, 2004, to December 30,2015, were retrospectively examined. Phenotypes were identified using latent class analysis of symptoms and PSG-based measures of sleep-disordered breathing and sleep architecture. Phenotypes were included as the primary predictor in a multivariable-adjusted Cox proportional hazard models for incident AF. RESULTS: In our cohort (N = 43,433, age 51.8 ± 14.5 years, 51.9% male, 74.9% White), 7.3% (n = 3,166) had baseline AF. Over a 7.6- ± 3.4-year follow-up period, 8.9% (n = 3,595) developed incident AF. Five phenotypes were identified. The hypoxia subtype (n = 3,245) had 48% increased incident AF (HR: 1.48; 95% CI: 1.34-1.64), the apneas + arousals subtype (n = 4,592) had 22% increased incident AF (HR: 1.22; 95% CI: 1.10-1.35), and the short sleep + nonrapid eye movement subtype (n = 6,126) had 11% increased incident AF (HR: 1.11; 95% CI: 1.01-1.22) compared with long sleep + rapid eye movement (n = 26,809), the reference group. The hypopneas subtype (n = 2,661) did not differ from reference (HR: 0.89; 95% CI: 0.77-1.03). CONCLUSIONS: Consistent with prior evidence supporting hypoxia as an AF driver and cardiac risk of the sleepy phenotype, this constellation of symptoms and physiologic alterations illustrates vulnerability for AF development, providing potential value in enhancing our understanding of integrated sleep-specific symptoms and physiologic risk of atrial arrhythmogenesis.

Adverse Cardiovascular Outcomes in Patients With Obstructive Sleep Apnea and Obesity: Metabolic Surgery vs Usual Care.

BACKGROUND: No therapy has been shown to reduce the risk of major adverse cardiovascular events (MACE) and death in patients with obstructive sleep apnea (OSA). OBJECTIVES: The authors sought to investigate the long-term relationship between metabolic surgery and incident MACE in patients with OSA and obesity. METHODS: Adult patients with a body mass index 35 to 70 kg/m2 and moderate-to-severe OSA at a U.S. health system (2004-2018) were identified. Baseline characteristics of patients who underwent metabolic surgery were balanced with a nonsurgical control group using overlap-weighting methods. Multivariable Cox regression analysis estimated time-to-incident MACE. Follow-up ended in September 2022. RESULTS: A total of 13,657 patients (7,496 [54.9%] men; mean age 52.0 ± 12.4 years; median body mass index 41.0 kg/m2 [Q1-Q3: 37.6-46.2 kg/m2]), including 970 patients in the metabolic surgery group and 12,687 patients in the nonsurgical group, with a median follow-up of 5.3 years (Q1-Q3: 3.1-8.4 years) were analyzed. The mean between-group difference in body weight at 10 years was 26.6 kg (95% CI: 25.6-27.6 kg) or 19.3% (95% CI: 18.6%-19.9%). The 10-year cumulative incidence of MACE was 27.0% (95% CI: 21.6%-32.0%) in the metabolic surgery group and 35.6% (95% CI: 33.8%-37.4%) in the nonsurgical group (adjusted HR: 0.58 [95% CI: 0.48-0.71]; P < 0.001). The 10-year cumulative incidence of all-cause mortality was 9.1% (95% CI: 5.7%-12.4%) in the metabolic surgery group and 12.5% (95% CI: 11.2%-13.8%) in the nonsurgical group (adjusted HR: 0.63 [95% CI: 0.45-0.89]; P = 0.009). CONCLUSIONS: Among patients with moderate-to-severe OSA and obesity, metabolic surgery, compared with nonsurgical management, was associated with a significantly lower risk of incident MACE and death.

Sex-specific differences in diagnostic approaches of inpatient sleep testing for obstructive sleep apnea.

BACKGROUND: Few studies have investigated sex-specific disparities in inpatient sleep testing. We postulate that women are more likely to have a milder degree of obstructive sleep apnea (OSA) and lower extent of hypoxia on Type III sleep studies versus polysomnography (PSG). PATIENTS AND METHODS: The Cleveland Clinic Sleep laboratory registry was leveraged to identify all adult inpatient sleep studies performed for OSA. Demographics, comorbidities, and sleep study measures were collected and compared by sex and sleep study type. Logistic regression was used to examine sleep study type predictive of OSA (apnea hypopnea index [AHI; ≥5, ≥15 and ≥ 30]) and hypoxia, (median percentage of sleep time spent at <90% SaO2 [TST<90%,≥ 11%,] adjusted for covariates. RESULTS: The sample 778 patients had a mean age of 56.1 ± 16.1 years; 44.5% were female and 72.2% Caucasian. At an AHI≥5, women showed an increase odds of OSA (adjusted, OR = 2.04,95%; CI:1.24-3.35, p = 0.005) with Type III sleep study vs PSG compared to men. At an AHI≥15, men had less odds of OSA (adjusted OR = 0.60,95%CI:0.39-0.90,p = 0.015) with Type III sleep study vs PSG compared to women (OR = 1.15,95%CI:0.72-1.85,p = 0.56), with an interaction p-value of 0.040. These results were attenuated when the analysis was restricted using the 3% hypopnea scoring rule. Men and women had higher odds of TST <90 ≥ 11% (OR:2.60,95%CI:1.60-4.21,p=<0.001; OR:3.46,95%CI:1.97-6.05,p < 0.001) with Type III sleep study versus PSG, albeit no sex-interaction was observed. CONCLUSIONS: These results suggest that sex-specific differences in diagnostic performance of sleep testing type in the inpatient setting should be considered according to level of OSA severity, which are influenced by hypopnea-related desaturation extent.

Association of Sleep-Related Hypoxia With Risk of COVID-19 Hospitalizations and Mortality in a Large Integrated Health System.

Importance: The influence of sleep-disordered breathing (SDB) and sleep-related hypoxemia in SARS-CoV-2 viral infection and COVID-19 outcomes remains unknown. Controversy exists regarding whether to continue treatment for SDB with positive airway pressure given concern for aerosolization with limited data to inform professional society recommendations. Objective: To investigate the association of SDB (identified via polysomnogram) and sleep-related hypoxia with (1) SARS-CoV-2 positivity and (2) World Health Organization (WHO)-designated COVID-19 clinical outcomes while accounting for confounding including obesity, underlying cardiopulmonary disease, cancer, and smoking history. Design, Setting, and Participants: This case-control study was conducted within the Cleveland Clinic Health System (Ohio and Florida) and included all patients who were tested for COVID-19 between March 8 and November 30, 2020, and who had an available sleep study record. Sleep indices and SARS-CoV-2 positivity were assessed with overlap propensity score weighting, and COVID-19 clinical outcomes were assessed using the institutional registry. Exposures: Sleep study-identified SDB (defined by frequency of apneas and hypopneas using the Apnea-Hypopnea Index [AHI]) and sleep-related hypoxemia (percentage of total sleep time at <90% oxygen saturation [TST <90]). Main Outcomes and Measures: Outcomes were SARS-CoV-2 infection and WHO-designated COVID-19 clinical outcomes (hospitalization, use of supplemental oxygen, noninvasive ventilation, mechanical ventilation or extracorporeal membrane oxygenation, and death). Results: Of 350 710 individuals tested for SARS-CoV-2, 5402 (mean [SD] age, 56.4 [14.5] years; 3005 women [55.6%]) had a prior sleep study, of whom 1935 (35.8%) tested positive for SARS-CoV-2. Of the 5402 participants, 1696 were Black (31.4%), 3259 were White (60.3%), and 822 were of other race or ethnicity (15.2%). Patients who were positive vs negative for SARS-CoV-2 had a higher AHI score (median, 16.2 events/h [IQR, 6.1-39.5 events/h] vs 13.6 events/h [IQR, 5.5-33.6 events/h]; P < .001) and increased TST <90 (median, 1.8% sleep time [IQR, 0.10%-12.8% sleep time] vs 1.4% sleep time [IQR, 0.10%-10.8% sleep time]; P = .02). After overlap propensity score-weighted logistic regression, no SDB measures were associated with SARS-CoV-2 positivity. Median TST <90 was associated with the WHO-designated COVID-19 ordinal clinical outcome scale (adjusted odds ratio, 1.39; 95% CI, 1.10-1.74; P = .005). Time-to-event analyses showed sleep-related hypoxia associated with a 31% higher rate of hospitalization and mortality (adjusted hazard ratio, 1.31; 95% CI, 1.08-1.57; P = .005). Conclusions and Relevance: In this case-control study, SDB and sleep-related hypoxia were not associated with increased SARS-CoV-2 positivity; however, once patients were infected with SARS-CoV-2, sleep-related hypoxia was an associated risk factor for detrimental COVID-19 outcomes.

Proteinuria y presión arterial de pacientes preeclámpticas severas y eclámpticas: relación con el resultante neonatal y la presencia de complicaciones maternas en pacientes de terapia intensiva del hospital gineco-obstétrico “Enrique C. Sotomayor” de enero a junio 2010 / Proteinuria and blood pressure of severe preeclamptic and eclamptic patients: Its relationship with the resultant neonatal and the presence of maternal complications in intensive care patients of the “Enrique C. Sotomayor” ob/gyn hospital from january to june 2010

Objetivo: determinar si los niveles de proteinuria y presión arterial de pacientes preeclámpticas severas y eclámpticas se relacionan con el resultante neonatal y la presencia de complicaciones maternas. Diseño: estudio observacional retrospectivo realizado con datos de las historias clínicas de pacientes en el área de terapia intensiva de hospital gineco-obstétrico “Enrique C. Sotomayor” con diagnóstico de preeclampsia severa y eclampsia, durante el periodo de enero a junio de 2010. Se obtuvieron datos maternos de presión arterial, proteinuria, resultados de laboratorio, edema y convulsiones; y score APGAR, test de Silverman, test de Ballard, clasificación del Lubchenco y peso del recién nacido. Se incluyeron mujeres de cualquier edad, gesta y edad gestacional. El análisis estadístico se realizó con el método chi-cuadrado en el programa de Microsoft Office Excel 2007. Los valores de p <0,05 fueron considerados estadísticamente significantes. Resultados: de 83 pacientes, 59 (71%) tuvieron preeclampsia severa y 24 (29%) eclampsia. Pacientes con presión arterial ≥140/90 mmHg, 45 (54.2%) tuvieron un neonato con Apgar ≥7 al minuto (p=0.73), 61 (73.4%) con Apgar ≥7 a los 5 minutos (p=0.17) y 12 (14.4%) pacientes presentaron complicaciones (p=0.64). Pacientes con proteinuria ≥300mg, 35 (42.1%) tuvieron un neonato con Apgar ≥7 al minuto (p=0.53), 48 (57.8%) con Apgar ≥7 a los 5 minutos (p=0.24) y 13 (15.6%) pacientes presentaron complicaciones (p=0.04; OR=6.5). Cuatro pacientes tuvieron 2 ó más complicaciones. Conclusión: los niveles elevados de proteinuria y presión arterial no disminuyen la vitalidad del neonato. Niveles elevados de proteinuria tienen mayor probabilidad de presentar complicaciones maternas.

Objective: to determine whether the levels of proteinuria and blood pressure of severe preeclamptic and eclamptic patients are associated with the resultant neonatal and the presence of maternal complications. Design: a retrospective observational study that used medical record data of patients diagnosed with severe preeclampsia and eclampsia in the Intensive care area of the “Enrique C. Sotomayor” ob/gyn hospital during the period from January to June 2010. Maternal data consisted of blood pressure, proteinuria, laboratory results, edema and convulsions; also APGAR score, Silverman test, Ballard test, Lubchenco classification, and the newborn’s weight. Women of any age and gestational state and age were included. The statistical analysis was performed using the chi-square method with Microsoft Office Excel 2007. P values of less than 0.05 were considered statistically significant. Results: of 83 patients, 59 (71%) had severe preeclampsia, and 24 (29%) eclampsia. Of the patients with blood pressure ≥ 140/90 mmHg, 45 (54.2%) had a neonate with Apgar ≥ 7 at 1 minute (p = 0.73), 61 (73.4%) with Apgar ≥ 7 at 5 minutes (p = 0.17), and 12 (14.4%) showed complications (p = 0.64). Of the patients with proteinuria ≥ 300 mg, 35 (42.1%) had a neonate with Apgar ≥ 7 at 1 minute (p = 0.53), 48 (57.8%) with Apgar ≥ 7 at 5 minutes (p = 0.24), and 13 (15.6%) showed complications (p = 0.04, OR = 6.5). Four patients had 2 or more complications. Conclusion: high levels of proteinuria and blood pressure do not diminish the vitality of the newborn. High levels of proteinuria are more likely to show maternal complications.