Effect of oral appliance therapy on blood pressure in Japanese patients with obstructive sleep apnea.

OBJECTIVE: Obstructive sleep apnea (OSA) treatment in patients with OSA and hypertension reduces blood pressure (BP). Oral appliance (OA) therapy is nowadays prescribed for patients with mild to moderate OSA. This study aimed to clarify the effect of OA therapy on BP reduction in Japanese patients with mild to moderate OSA. METHODS: Polysomnography was employed to detect sleep-disordered breathing. Totally, 237 patients without cardiac and/or cerebrovascular diseases and those with apnea-hypopnea index (AHI) ≥ 5/h-< 30/h were enrolled. Office BP change after receiving 8-12 weeks of OA therapy was assessed and the factors related to the degree of BP reduction were analyzed. RESULTS: The study patients consisted of 188 men and 49 women, the mean age was 54.7 ± 13.2 years old, and the body mass index (BMI) was 24.6 ± 3.4 kg/m(2). The antihypertensive effect of OA therapy resulted in systolic BP (SBP) -2.4 ± 14.8 (p = 0.078) and diastolic BP (DBP) -2.0 ± 11.7 mm Hg (p = 0.045) in all patients. SBP before OA therapy played a significant role in the degree of SBP reduction (ß = -0.597, p < 0.001), whereas DBP before OA therapy was a significant factor of the degree of DBP reduction (ß = -0.522, p < 0.001). CONCLUSION: A certain time period of OA therapy effected BP reduction in mild to moderate OSA patients without cardiac and/or cerebrovascular diseases. Its antihypertensive effect was greater in OSA patients whose BP was higher before receiving OA therapy.

Differences in physical performance based on the Geriatric Nutritional Risk Index in elderly female cardiac patients.

BACKGROUND AND AIMS: Little is known about differences in the risk of poor nutritional status as assessed by the Geriatric Nutritional Risk Index (GNRI) in relation to physical performance in elderly female cardiac inpatients. The present study aimed to determine both differences in physical performance based on the GNRI and physical performance cut-off values according to the GNRI in elderly female cardiac inpatients. METHODS: We enrolled 105 consecutive female Japanese inpatients aged ≥65 years (mean age, 74.6 years) with cardiac disease in this cross-sectional study. We divided the patients into two groups according to GNRI: high-GNRI group (≥92 points) (n = 71) and low-GNRI group (<92 points) (n = 34). Handgrip strength (HG), knee extensor muscle strength (KEMS), gait speed (GS), and one-leg standing time (OLST) were assessed as indices of hospital physical performance and compared between the two groups to determine cut-off values of physical performance. RESULTS: After adjustment for age and left ventricular ejection fraction, HG, KEMS, GS, and OLST were significantly lower in the low-GNRI versus high-GNRI group. Cut-off values by ROC curve analysis were 16.2 kgf (AUC = 0.66; p < 0.001) for HG, 34.3 % of body weight (AUC = 0.62; p = 0.04) for KEMS, 1.24 m/s (AUC = 0.72; p < 0.01) for GS, and 8.28 s (AUC = 0.62; p = 0.04) for OLST. CONCLUSION: The risk of poor nutrition, as indicated by a low GNRI, might be a predictor of lower physical performance. Cut-off values determined in this study might be minimum target goals for physical performance that can be attained by elderly female cardiac inpatients.

Knee extensor muscle strength and index of renal function associated with an exercise capacity of 5 metabolic equivalents in male chronic heart failure patients with chronic kidney disease.

BACKGROUND: The goal of the present study was to determine knee extensor muscle strength (KEMS) and degree of renal dysfunction associated with an exercise capacity of ≥5 metabolic equivalents (METs) in male chronic heart failure (CHF) patients with chronic kidney disease (CKD). METHODS: In this cross-sectional study of 75 male CHF patients with CKD (65.3 ± 11.6 years), we measured clinical characteristics, peak [Formula: see text], estimated glomerular filtration rate (eGFR), and KEMS. Patients were divided into two groups by exercise capacity: ≥5 METs group (n = 41) and <5 METs group (n = 34). Cutoff values for KEMS and eGFR resulting in an exercise capacity of ≥5 METs were selected with ROC curves. Patients were divided into four groups according to cutoff values, and numbers of patients attaining an exercise capacity of ≥5 METs were compared between groups. RESULTS: Age was significantly higher although eGFR, Hb, and KEMS were lower in the <5 METs versus ≥5 METs group (P < 0.001). Multiple logistic regression analysis revealed a positive significant relation between KEMS and eGFR and exercise capacity of ≥5 METs. Exercise capacity of ≥5 METs was associated with KEMS of approximately 1.69 Nm/kg and an eGFR of 45.7 mL/min/1.73 m(2). The number of patients attaining an exercise capacity of ≥5 METs in the patients who did not reach both cutoff values was significantly lower than that in any other patients (P < 0.001). CONCLUSION: KEMS and eGFR may be useful indices for predicting attainment of exercise capacity of ≥5 METs in male CHF patients with CKD.

Differences in daily in-hospital physical activity and geriatric nutritional risk index in older cardiac inpatients: preliminary results.

BACKGROUND: Little is known about the differences in the geriatric nutritional risk index (GNRI) status in older patients and their relationship to accelerometer-derived measures of physical activity (PA) levels. We determined both differences in daily measured PA based on the GNRI and related cut-off values for PA in elderly cardiac inpatients. METHODS: We divided 235 consecutive elderly cardiac inpatients (mean age 73.6 years, men 70.6%) into four groups by age and GNRI: older-high group, 65-74 years with high GNRI (≥92 points) (n = 111); older-low group, low GNRI (<92 points) (n = 30); very old-high group, ≥75 years with high GNRI (n = 55); and very old-low group with low GNRI (n = 39). Average step count and physical activity energy expenditure (PAEE in kcal) per day for 2 days of these inpatients were assessed by accelerometer and compared between the four groups to determine cut-off values of PA. RESULTS: Step counts and PAEE were significantly lower in the low-GNRI versus high-GNRI groups in the older (2,742.1 vs. 4,198.1 steps, 55.4 vs. 101.3 kcal, P < 0.001), and very old (2,469.6 vs. 3,423.7 steps, 54.5 vs. 79.1 kcal, P < 0.001) cardiac inpatients. Respective cut-off values for step counts and PAEE were 3,017.6 steps/day and 69.4 kcal (P < 0.01) in the older and 2,579.4 steps/day and 58.8 kcal in the very old cardiac inpatients (P < 0.01). CONCLUSION: Poor nutritional status, as indicated by a low GNRI, may be a useful predictor of step counts and PAEE. The cut-off values determined in this study might be target values to be attained by older cardiac inpatients.

[Sleep apnea syndrome: SAS].

Obstructive sleep apnea (OSA) is an independent risk factor for hypertension and cardiovascular disease. OSA is the frequent underlying disease of secondary hypertension and resistant hypertension. In 2003, the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure recognized sleep apnea as a common and identifiable cause of hypertension and suggested blood pressure screening among patients with OSA. OSA increases both daytime and nocturnal ambulatory blood pressures through the activation of various neurohumoral factors including the sympathetic nervous system and the renin-angiotensin-aldosterone system. Randomized, controlled trials have evaluated the use of continuous positive airway pressure (CPAP) to reduce BP among persons with OSA. The benefits of OSA treatment are related to implications for hypertension management.

Sleep disordered breathing in heart failure patients with reduced versus preserved ejection fraction.

BACKGROUND: This study aimed to investigate and compare prevalence of sleep disordered breathing (SDB) in Japanese patients with heart failure with reduced ejection fraction (HFrEF) versus those with HF with preserved EF (HFpEF). METHODS: This study consecutively included 101 Japanese patients (77 males) with de novo CHF. Echocardiography was performed twice, on admission and at discharge. All patients underwent portable overnight polygraphy within one week before discharge. The patients were stratified into two groups based on LVEF on admission, HFrEF (R group; LVEF<50%, n=82) or HFpEF (P group; LVEF≧50%, n=19); the prevalence of SDB and sleep study data were assessed. RESULTS: When patients with the apnea hypopnea index ≥15 were defined as having SDB, 50% of the study patients had SDB (OSA, 10%; CSA, 39%; MSA, 1%). No significant differences in the prevalence of SDB or sleep data as well as RVSP, E/e' or plasma brain natriuretic peptide (BNP) were found between the two groups. CONCLUSIONS: SDB was identified in 50% of de novo Japanese HF patients. When E/e', RVSP and plasma BNP did not significantly differ between the two groups, the prevalence of SDB was similar regardless of LVEF.

Hospital-acquired disability in older heart failure patients decreases independence and increases difficulties in activities of daily living.

AIMS: The aim of this study was to clarify whether worsening of independence in activities of daily living (ADL) and also difficulties in ADL are triggered by hospitalization in older patients with heart failure (HF) and whether difficulties in ADL can predict readmission for HF regardless of independence in ADL in these patients. METHODS AND RESULTS: We enrolled 241 HF patients in the present multi-institutional, prospective, observational study. The patients were divided according to age into the non-older patient group (<75 years, n = 137) and the older patient group (≥75 years, n = 104). The Katz index and the Performance Measure for Activities of Daily Living-8 (PMADL-8) were used to evaluate independence and difficulties in ADL, respectively. The endpoint of this study was rehospitalization for HF. Independence as indicated by the Katz index at discharge was significantly lower than that before admission only in the older patient group, and the value of the PMADL-8 at discharge was significantly higher than that before admission (P < 0.001). In all patients, after adjusting for the Katz index and other variables, PMADL-8 score was a significant predictor of rehospitalization for HF (hazard ratio 1.50; 95% confidence interval 1.07-2.13; P = 0.021). CONCLUSIONS: Worsening of both independence and difficulties in ADL was triggered by hospitalization in older HF patients, and difficulties in ADL were relevant factors for risk of rehospitalization regardless of independence in ADL. These findings indicate the importance of preventing not only decreased independence but also increased difficulties in ADL during and after hospitalization.

Determination of the effectiveness of accelerometer use in the promotion of physical activity in cardiac patients: a randomized controlled trial.

OBJECTIVE: To investigate the effect of the self-monitoring of physical activity by hospitalized cardiac patients attending phase I cardiac rehabilitation (CR). DESIGN: Randomized controlled trial. SETTING: University hospital CR program. PARTICIPANTS: CR patients (N=126) with a mean age of 59.1 years. INTERVENTIONS: Patients were randomly assigned to the self-monitoring group (group A, n=63) or the control group (group B, n=63). Along with CR, group A patients performed self-monitoring of their physical activity at the beginning of a phase I CR program (acute in-hospital phase for inpatients) and ending just before they began a phase II CR program (postdischarge recovery phase for outpatients). MAIN OUTCOME MEASURES: Physical activity (averages of daily number of steps taken and daily energy expenditure for 1wk) as measured by accelerometer was assessed in both groups at baseline (t1) and before the beginning of phase II CR (t2). RESULTS: Although there were no significant differences in physical activity values between groups A and B at t1, values of group A at t2 were significantly higher than those of group B (8609.6 vs 5512.9 steps, P<.001; 242.6 vs 155.9kcal, P<.001). CONCLUSIONS: Self-monitoring of patient physical activity from phase I CR might effectively increase the physical activity level in preparation for entering a phase II CR program. Results of the present study could contribute to the development of new strategies for the promotion of physical activity in cardiac patients.

Relevant factors of leg strength at hospital discharge in patients hospitalized due to acute decompensated heart failure: multi-institutional prospective observational study.

BACKGROUND: Lower leg strength at hospital discharge is strongly associated with poor prognosis in older patients with acute decompensated heart failure (ADHF). Improving leg strength is important in acute-phase cardiac rehabilitation (CR). AIMS: This study aimed to clarify whether a change in leg strength occurs during hospitalization of older ADHF patients receiving CR and whether it affects leg strength at discharge. METHODS AND RESULTS: We enrolled 247 ADHF patients who underwent CR during hospitalization. They were divided into the non-older patient group (<75 years; n = 142) and older patient group (≥75 years; n = 105). Quadriceps isometric strength (QIS), body mass-corrected QIS (%BM QIS), and change in QIS during hospitalization (QIS ratio) were evaluated in all patients. Physical function in the stable phase was measured by the Performance Measure for Activities of Daily Living-8 (PMADL-8). The QIS value increased during hospitalization in the non-older patient group (30.0 ± 11.1 vs. 31.6 ± 10.9 kgf, P < 0.001) but did not increase in the older patient group (19.1 ± 6.3 vs. 19.5 ± 6.1 kgf, P = 0.275). Multiple regression analysis revealed that PMADL-8 significantly predicted %BM QIS at discharge in the non-older patient group (ß = -0.254, P = 0.004), whereas in the older patient group, QIS ratio and PMADL-8 significantly predicted %BM QIS at discharge (ß = 0.264, P = 0.008 for QIS ratio and ß = -0.307, P = 0.003 for PMADL-8). CONCLUSIONS: Leg strength was not improved in older ADHF patients during hospitalization even if they received CR, and this affected leg strength at discharge, suggesting that careful skeletal muscle intervention should be provided during hospitalization, and patients need to continue exercise after discharge.

Changes in mitral regurgitation and left ventricular geometry during exercise affect exercise capacity in patients with systolic heart failure.

AIMS: exercise may dramatically change the extent of functional mitral regurgitation (MR) and left ventricular (LV) geometry in patients with chronic heart failure (CHF). We hypothesized that dynamic changes in MR and LV geometry would affect exercise capacity. METHODS AND RESULTS: this study included 30 CHF patients with functional MR who underwent symptom-limited bicycle exercise stress echocardiography and cardiopulmonary exercise testing for quantitative assessment of MR (effective regurgitant orifice; ERO), and pulmonary artery systolic pressure (PASP). LV sphericity index was obtained from real-time three-dimensional echocardiograms. The patients were stratified into exercised-induced MR (EMR; n = 10, an increase in ERO by ≥13 mm(2)) or non-EMR (NEMR; n = 20, an increase in ERO by <13 mm(2)) group. At rest, no differences in LV volume and function, ERO, and PASP were found between the two groups. At peak exercise, PASP and sphericity index were significantly greater (all P < 0.01) in the EMR group. The EMR group revealed lower peak oxygen uptake (peak VO(2); P = 0.018) and greater minute ventilation/carbon dioxide production slope (VE/VCO(2) slope; P = 0.042) than the NEMR group. Peak VO(2) negatively correlated with changes in ERO (r = -0.628) and LV sphericity index (r = -0.437); meanwhile, VE/VCO(2) slope was well correlated with these changes (r = 0.414 and 0.364, respectively). A multivariate analysis identified that the change in ERO was the strongest predictor of peak VO(2) (P = 0.001). CONCLUSION: dynamic changes in MR and LV geometry contributed to the limitation of exercise capacity in patients with CHF.

[Sleep apnea and hypertension].

Obstructive sleep apnea (OSA) is strongly associated with hypertension. The seventh report of the joint national committee (JNC-VII) guidelines have placed OSA at the top of the list to induce secondary hypertension. Severe OSA patients revealed the high prevalence of hypertension. Compared with normal subjects, patients with OSA had a higher 24-hour blood pressure, especially nighttime blood pressure. More recently, prospective data showed that sleep apnea syndrome was an independent risk for onset of hypertension. There is a lot of evidence that demonstrates that treating OSA using continuous positive airway pressure (CPAP) is an effective for management of OSA.

Handgrip strength as a predictor of prognosis in Japanese patients with congestive heart failure.

BACKGROUND: Whether upper-extremity and lower-extremity muscle strength can predict a prognosis of congestive heart failure (CHF) patients is unclear. This study evaluated the impact of muscle strength on long-term mortality in patients with CHF. DESIGN: Prospective observational study of male Japanese CHF patients. METHODS: Clinical characteristics (age, body mass index, left ventricular ejection fraction, heart failure etiology, and medications) were obtained from hospital records of 148 male outpatients with stable CHF. Brain natriuretic peptide was determined as an index of disease severity. Peak oxygen uptake ((Equation is included in full-text article.)), handgrip, and knee extensor muscle strength were also determined. RESULTS: After 1331.9+/-700.3 days of follow-up, 13 cardiovascular-related deaths occurred, and the patients were divided into two groups: survival (n=135) and nonsurvival (n=13). No significant differences were found between the groups in clinical characteristics, brain natriuretic peptide levels, and knee extensor muscle strength. Peak(Equation is included in full-text article.)(P=0.011) and handgrip strength (P=0.008) were significantly lower in the nonsurvival versus survival group. Left ventricular ejection fraction, peak(Equation is included in full-text article.), and handgrip strength were found by univariate Cox proportional hazards analysis to be significant prognostic indexes of survival. Multivariate analysis, however, revealed handgrip strength to be an independent predictor of prognosis. A handgrip strength cutoff value of 32.2 kgf was determined by the analysis of receiver-operating characteristics and was assessed. Kaplan-Meier survival curves after log-rank test showed significant prognostic difference between the two groups (P=0.008). CONCLUSION: Handgrip strength may be useful for forecasting prognosis in patients with CHF.

Oxygen uptake kinetics during and after exercise are useful markers of coronary artery disease in patients with exercise electrocardiography suggesting myocardial ischemia.

BACKGROUND: The aim of the current study was to determine if the slowed exercise oxygen uptake (VO(2)) kinetics, which is developed by myocardial ischemia, would be accompanied by delayed recovery VO(2) kinetics in patients with coronary artery disease (CAD). METHODS AND RESULTS: Thirty-seven patients with significant ST depression during treadmill exercise underwent cardiopulmonary exercise testing with cycle ergometer. Measurements performed are the ratios of change in increase in oxygen (O(2)) uptake relative to increase in work rate (DeltaVO(2)/DeltaWR) across anaerobic threshold (AT) and 1 mm ST depression point (ST-dep), the time constants of VO(2) during recovery (T(1/2) VO(2)), stress radio-isotope scintigraphy and coronary angiography. Patients were divided into CAD positive (CAD+) and CAD negative (CAD-) groups, based on coronary angiography. In CAD+, DeltaVO(2)/DeltaWR decreased above AT and ST-dep, in contrast to CAD- patients. The T(1/2) VO(2) in CAD+ (103.1 +/-13.0 s) was greater than that of CAD- (76.5 +/-8.7 s) and showed negative correlations to the ratios of DeltaVO(2)/DeltaWR across AT and ST-dep. These parameters improved in the patients who underwent coronary bypass surgery. CONCLUSIONS: Exercise and recovery VO(2) kinetics were slowed when myocardial ischemia was provoked by exercise. Measurement of exercise and recovery VO(2) kinetics improve the accuracy of the exercise electrocardiogram diagnosis of CAD.

Three-dimensional echocardiographic assessments of exercise-induced changes in left ventricular shape and dyssynchrony in patients with dynamic functional mitral regurgitation.

AIMS: Left ventricular (LV) shape and LV dyssynchrony are two cofactors associated with functional mitral regurgitation (MR) in patients with heart failure. Both can be accurately examined by real-time three-dimensional echocardiography (3DE). We examined the relationship between dynamic MR and exercise-induced changes in LV shape and synchronicity using 3DE. METHODS AND RESULTS: Fifty patients with systolic LV dysfunction underwent 2D and 3D quantitative assessment of LV function, shape, and synchronicity at rest and during symptom-limited exercise test. According to the magnitude of change in MR, patients were divided into EMR group (15 patients, 30%), if the degree of MR increased during test, and NEMR group. During exercise, the changes in LV volumes and ejection fraction were similar in both groups, whereas changes in mitral valvular deformation parameters, in LV sphericity index, and in the extent of LV dyssynchrony were more pronounced in the EMR group. At rest, only the 3D sphericity index could distinguish the two groups. By stepwise multiple regression model, dynamic changes in the systolic dyssynchrony index, sphericity index, and coaptation distance were associated with dynamic MR (r(2) = 0.45, P = 0.012). CONCLUSION: Dynamic MR during exercise is related to the 3D changes in LV shape and in LV synchronicity.

Diurnal blood pressure variation in patients with sleep apnea syndrome.

Sleep apnea syndrome (SAS) is an important risk factor for hypertension and cardiovascular diseases. Diurnal blood pressure (BP) changes are evaluated by 24 h ambulatory blood pressure monitoring (ABPM). The purpose of this study was to clarify the relationship between diurnal BP variation and SAS severity, as well as the impact of antihypertensive therapy on diurnal BP variation. Patients seen at our clinic between April and September 2006 with excessive daytime sleepiness or apnea were enrolled. All patients had polysomnography and ABPM. Mean 24 h BP and nighttime BPs were significantly higher in the SAS group than in the non-SAS group. No significant differences were observed in daytime BPs between the two groups. SAS patients had a high mean 24-h BP and an elevated nighttime BP, both of which increased as SAS severity increased. Nighttime BPs were significantly higher in the moderate SAS group than in the non-SAS group. Nighttime BP and morning BP were significantly higher in the severe SAS group than in the non-SAS group. With respect to antihypertensive agents' effects on diurnal BP changes, there were no significant differences between the SAS and non-SAS groups. In conclusion, compared with non-SAS patients, patients with SAS had a higher 24-h BP, especially nighttime BP. Patients with moderate SAS tended to have elevated nighttime BP. In patients with severe SAS, elevated BP was sustained during the night despite the use of antihypertensive agents.

The Factors Affecting the Non-dipper Pattern in Japanese Patients with Severe Obstructive Sleep Apnea.

Objective Obstructive sleep apnea (OSA) is assumed to influence the circadian blood pressure (BP) fluctuation, particularly causing nocturnal hypertension and changing the dipping pattern of nocturnal BP. This study aimed to clarify the triggers of the non-dipper pattern in nocturnal BP in Japanese patients with severe OSA (the apnea-hypopnea index ≥30/h). Methods Of 541 patients with OSA diagnosed using polysomnography (PSG) and ambulatory BP monitoring (ABPM), 163 patients <60 years of age (Younger group) and 101 patients ≥60 years of age (Older group) were stratified into the dipper or non-dipper pattern groups. Results A logistic regression analysis was performed using a non-dipper pattern as a dependent variable. A multivariate analysis demonstrated that the cumulative percentage of time at saturation below 90% was the only independent risk factor for the non-dipper and riser patterns in the Younger group (odds ratio, 1.022; 95% confidence interval, 1.001-1.044; p=0.035), whereas slow-wave sleep (odds ratio, 0.941; 95% confidence interval, 0.891-0.990; p=0.019) and the use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (odds ratio, 2.589; 95% confidence interval, 1.051-6.848; p=0.039) were risk factors in the Older group. Conclusion These findings suggested that the degree of desaturation in young OSA patients and sleep quality in old OSA patients might influence the dipping patterns in nocturnal BP.

Impact of obstructive sleep apnea and hypertension on left ventricular hypertrophy in Japanese patients.

The incidence of cardiovascular disease and mortality rates are high among patients with left ventricular hypertrophy (LVH). Obstructive sleep apnea (OSA) has been reported to increase left ventricular mass (LVM) and cause LVH. The prevalence of hypertension, a major cause of increased LVM, is high in OSA; however, it is still unknown whether OSA is an independent factor that increases LVM in addition to triggering LVH. This study investigated out-of-office blood pressure (BP) via ambulatory BP monitoring (ABPM) in patients with OSA diagnosed by polysomnography (PSG) and sought to determine the effects of OSA and hypertension on LVM. A total of 432 patients with OSA underwent ABPM and echocardiography. These patients were stratified into four groups according to their left ventricular mass index (LVMI) quartiles, and the component factors influencing LVMI, such as patient background, sleep data and all-day BP data, were analyzed. This study included 356 men and 76 women. The mean age was 54.6±13.2 years, the mean body mass index was 26.7±4.6 kg m-2 and the mean apnea-hypopnea index (AHI) was 37.9±22.5. Multivariate analysis indicated that antihypertensive agent use (ß=0.143, P=0.002), an AHI ⩾15/h (ß=0.100, P=0.045) and 24-h systolic BP (ß=0.252, P<0.001) were significant independent factors for increased LVM. The significant LVMI component factors in OSA patients were an AHI ⩾15/h and 24-h systolic BP. The results of this study demonstrated that both elevated BP and OSA were independently associated with increased LVM.