SAS score: Targeting high-specificity for efficient population-wide monitoring of obstructive sleep apnea.

PROPOSAL: This paper investigates a novel screening tool for Obstructive Sleep Apnea Syndrome (OSAS), which aims at efficient population-wide monitoring. To this end, we introduce SASscore which provides better OSAS prediction specificity while maintaining a high sensitivity. METHODS: We process a cohort of 2595 patients from 4 sleep laboratories in Western Romania, by recording over 100 sleep, breathing, and anthropometric measurements per patient; using this data, we compare our SASscore with state of the art scores STOP-Bang and NoSAS through area under curve (AUC), sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV). We also evaluate the performance of SASscore by considering different Apnea-Hypopnea Index (AHI) diagnosis cut-off points and show that custom refinements are possible by changing the score's threshold. RESULTS: SASscore takes decimal values within the interval (2, 7) and varies linearly with AHI; it is based on standardized measures for BMI, neck circumference, systolic blood pressure and Epworth score. By applying the STOP-Bang and NoSAS questionnaires, as well as the SASscore on the patient cohort, we respectively obtain the AUC values of 0.69 (95% CI 0.66-0.73, p < 0.001), 0.66 (95% CI 0.63-0.68, p < 0.001), and 0.73 (95% CI 0.71-0.75, p < 0.001), with sensitivities values of 0.968, 0.901, 0.829, and specificity values of 0.149, 0.294, 0.359, respectively. Additionally, we cross-validate our score with a second independent cohort of 231 patients confirming the high specificity and good sensitivity of our score. When raising SASscore's diagnosis cut-off point from 3 to 3.7, both sensitivity and specificity become roughly 0.6. CONCLUSIONS: In comparison with the existing scores, SASscore is a more appropriate screening tool for monitoring large populations, due to its improved specificity. Our score can be tailored to increase either sensitivity or specificity, while balancing the AUC value.

Obesity in association with Sleep Apnea Syndrome as predictor for coronary-vascular comorbidities.

BACKGROUND AND AIMS: Sleep apnea syndrome (SAS) is a common disorder with growing awareness. We sought to evaluate if the presence of obesity in patients with SAS is associated with a high risk for development of coronary-vascular comorbidities. METHODS: We performed a retrospective study that included 1370 patients (30.3% female and 69.7% male) diagnosed with SAS from May 2005 to May 2012. The collected data included body mass index (BMI), waist/ hip ratio, abdominal, neck, hip circumference and Epworth Sleepiness Scale. The positive diagnostic of SAS was based on apnea-hypopnea index (AHI) provided by polysomnography, and patient comorbidities were obtained from the sleep laboratory records. RESULTS: From the total of 1370 patients, 989 (72%) had grade I to III obesity, 305 (22%) were overweight and only 76 (6%) had a normal weight. Cardiovascular comorbidities were presented in 60.6% of patients, with coronary disease ranking first (34.2%) followed by heart failure (22.6%) and stroke (3.8%). The predictors for cardiovascular comorbidities were coronary disease (OR 2.1, 95% Cl 1.20-3.39, p = 0.0063), heart failure (OR 3.44, 95% Cl 1.60-7.74, p < 0.001) but not stroke (OR 2.3 95% Cl 0.57-13.84, p = 0.357). Analyzing the polysomnography parameters we found a strong correlation for AHI (p < 0.0001), oxygen desaturation index (p < 0.0001) and mean average oxyhaemoglobin saturation (p < 0.0001). CONCLUSIONS: Overweight and obese patients with SAS have a poor outcome, being at high risk of developing other comorbidities like coronary disease and heart failure.

Prognostic value of septal E/(E'×S') ratio in predicting cardiac death in patients with heart failure.

BACKGROUND: A new tissue Doppler index, E/(E'×S'), including the early diastolic transmitral/mitral annular velocity (E/E') ratio and systolic mitral annular velocity (S'), has a good accuracy in predicting left ventricular filling pressure. AIM: To investigate the value of E/(E'×S') measured at different sites of the mitral annulus to predict cardiac death in patientswith heart failure (HF). METHODS: Echocardiography was performed in 342 consecutive hospitalised patients with HF, in sinus rhythm, at hospital discharge and after one month. Velocities were determined at septal and lateral mitral annular sites, and average values obtained. E/(E'×S') worsening was defined as a value greater than the value determined at discharge. The end point was cardiac death. RESULTS: During the follow-up period (35 ± 8.8 months), cardiac death occurred in 52 (15.2%) patients. Septal E/(E'×S') at hospital discharge presented the largest area under receiver operating characteristic (ROC) curve to predict cardiac death (0.85,95% CI 0.79-0.90, p < 0.001). A statistical comparison of the ROC curves demonstrated no significant differences between septal and average E/(E'×S') (p = 0.54), but the accuracy of septal E/(E'×S') was better compared to the other analysed echocardiographic parameters [E/(E'×S'), E/E', S', etc., all p < 0.05]. The optimal septal E/(E'×S') cut-off was 3.03 (75% sensitivity,83% specificity). Before discharge, 96 (28.1%) patients presented septal E/(E'×S') > 3.03. Cardiac death was significantly higher in patients with E/(E'×S') > 3.03 (39 deaths, 40.2% vs. 13 deaths, 5.3%, p < 0.001). Patients with septal E/(E'×S') > 3.03 at discharge and worsening after one month presented the worst prognosis in the overall population. CONCLUSIONS: Septal E/(E'×S') is a powerful predictor of cardiac death in patients with HF.

Dual renin angiotensin system blockade in patients with acute myocardial infarction and preserved left ventricular systolic function.

UNLABELLED: The activation of the renin-angiotensin system (RAS) is a major determinant of ventricular remodeling. We prospectively assessed whether the dual RAS blockade (angiotensin II AT 1-receptor blocker and angiotensin-converting enzyme inhibitor therapy) in patients with acute myocardial infarction (AMI) who were treated by primary percutaneous coronary intervention (PCI) and stenting provides benefit on the improvement of the left ventricle function. A secondary aim is to demonstrate that triple therapy with angiotensin-converting enzyme (ACE) inhibitors, angiotensin II AT 1-receptor blockers (ARBs) and beta blockers does not increase cardiovascular morbidity, cardiovascular mortality and all cause mortality. METHODS: We investigated 44 patients with AMI with ST elevation undergoing primary PCI and stenting. All patients received standard therapy including an ACE inhibitor and a beta blocker. We divided the patients into two groups, A and B. Valsartan was added to the standard therapy within the first 6 hours from the onset of AMI in group A. We assessed cardiovascular and all cause mortality, incidence of major acute coronary events (MACE), incidence of non-fatal AMI, the evolution of left ventricle ejection fraction (LVEF), wall motion score index (WMSI) and left ventricle end-systolic and end-diastolic diameters. The follow-up period was one year. RESULTS: There were no statistically significant differences between groups regarding cardiovascular and all cause mortality, incidence of MACE, incidence of non-fatal MI. LVEF significantly increased at 1 year in both groups. In both groups the reduction of end-systolic and end-diastolic diameters at 1 year was statistically significant. Echocardiographic findings demonstrated also a significant decrease of WMSI at 1 year in both groups. CONCLUSIONS: The dual renin-angiotensin system blockade (ARBs and ACE inhibitor) has proved its beneficial effect on the improvement of left ventricular function, without increasing cardiovascular mortality and incidence of non fatal myocardial infarction (MI) in patients with AMI treated by primary PCI and stenting within a 1 year follow-up period.