Cardiovascular Risk: Causal Association With Sleep Apnea “Hard to Establish” Until Now

Researchers from Brigham and Women’s Hospital Results indicate that obstructive sleep apnea is associated with subclinical myocardial injury—and that high-sensitivity troponin T may serve as an early marker of the adverse myocardial impact of obstructive sleep apnea.

“Although obstructive sleep apnea is associated with increased cardiovascular risk, a causal association has been hard to establish because of the association of obstructive sleep apnea with other risk factors,” said Amil M. Shah, MD, MPH, of Brigham and Women’s Hospital. “In a new study, we were able to demonstrate that greater obstructive sleep apnea severity is independently associated with higher high-sensitivity troponin T levels, suggesting a role for subclinical myocardial injury in the relationship between obstructive sleep apnea and heart failure.”

Cardiology Today reports that this is the first study to demonstrate an independent association between sleep apnea severity and this marker of early myocardial injury.

The new study titled “Sleep Apnea is Associated with Subclinical Myocardial Injury in the Community: The ARIC-SHHS Study“ included 1,645 middle-aged and older participants in the Atherosclerosis Risk in Communities (ARIC) study and the Sleep Health Study. All were free of CHD and HF at baseline.

Read Abstract Here

According to Cardiology Today, median follow-up was 12.4 years. Participants underwent overnight home polysomnography. Obstructive sleep apnea severity, measured by the respiratory disturbance index (RDI), was categorized as none (RDI ≤5), mild (RDI 5-15), moderate (RDI 15-30) or severe (RDI ≥30).

High-sensitivity troponin T levels, but not NT-proBNP levels, were significantly associated with obstructive sleep apnea after adjustment for 17 potential confounders (P=.02). In all obstructive sleep apnea severity categories, high-sensitivity troponin T was significantly related to the risk for death or incident HF; this relationship was strongest in the severe obstructive sleep apnea group.

Limitations of the study include its cross-sectional design and a limited number of participants with obstructive sleep apnea. “Our results suggest a relationship between subclinical myocardial injury and the increased cardiovascular risk seen in patients with obstructive sleep apnea,” Shah said. “Monitoring of high-sensitivity troponin T levels in these patients may have prognostic value, particularly in patients with severe obstructive sleep apnea.”

Source: ATS Journals

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Chest 2013 Update – “Exposure Therapy” is Latest Wrinkle in Battle for CPAP Compliance

An effort to desensitize patients to CPAP masks may ease the transition for patients and ultimately boost compliance. The small-sample “exposure therapy” pilot study concluded that patients were able to significantly increase the number of minutes per night on CPAP after the desensitization program.

As reported from the CHEST Meeting in Chicago, IL, “Evaluation of a continuous positive airway pressure desensitization protocol for CPAP-intolerant patients: A pilot study“, some patients who had been unable to tolerate the treatment, mostly because of an inability to wear the mask properly, were able to significantly increase the number of minutes per night on CPAP

Click her to read Meeting Abstract CHEST 2013; 144: 979A

A report from Patricia Dettenmeier, MSN, of Saint Louis University, and colleagues, deemed CPAP desensitization a “potential therapy for patients with obstructive sleep apnea and claustrophobia or mask intolerance even after several years of non-use or inadequate use.”

Dettenmeier and colleagues tested an exposure-therapy protocol in 22 patients who had problems with CPAP compliance. The protocol, which was implemented by a nurse practitioner, involved several techniques for getting patients used to the mask.

According to Dettenmeier, patients were instructed to wear the mask while awake for an hour each day with the mask attached to the CPAP device and the device switched on in order to practice breathing through the mask. Patients could do this while watching television, reading, or doing some other sedentary activity.

Within a month of starting the exposure therapy, Dettenmeier reported, 10 patients were able to use CPAP and seven were fully adherent. Those who were adherent spent significantly more minutes using the treatment than those who were not adherent (339.5 min versus 47.22 min, P<0.001).
Source: American College of Chest Physicians 



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New Research: Sleep Disorders Tied to Alzheimer’s Biomarker

As reported in the Washington Post, poor sleep quality may impact Alzheimer’s disease onset and progression. This is according to a new study led by researchers at the Johns Hopkins Bloomberg School of Public Health who examined the association between sleep variables and a biomarker for Alzheimer’s disease in older adults.

Published in the October issue of JAMA Neurology “Self-reported Sleep and β-Amyloid Deposition in Community-Dwelling Older Adults“, the researchers found that reports of shorter sleep duration and poorer sleep quality were associated with a greater β-Amyloid burden, a hallmark of the disease.

Read Abstract Here

Previous studies had linked disturbed sleep to cognitive impairment in older people. The new findings suggest that sleep problems may contribute to its development.

Post reporters point out that it is not yet known whether amyloid plaque causes Alzheimer’s, or is a byproduct of it. According to the Post, a team led by Adam Spira of the Johns Hopkins Bloomberg School of Public Health examined sleep as reported by research participants.

Their duration of sleep ranged from more than seven hours a night to no more than five hours. Beta-amyloid in their brains was measured by positron emission tomography, or PET scans.

The results: Shorter sleep duration and lower sleep quality were both associated with greater beta-amyloid buildup. “These findings are important in part because sleep disturbances can be treated in older people,” Spira says. “To the degree that poor sleep promotes the development of Alzheimer’s disease, treatments for poor sleep or efforts to maintain healthy sleep patterns may help prevent or slow the progression of Alzheimer’s disease.”

Source: John Hopkins Bloomberg School of Public Health

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Third Quarter Revenue Up at ResMed

San Diego-based ResMed Inc posted third quarter revenue of $357.7 million, a 5% increase over the quarter ended September 30, 2012. For the quarter ended September 30, 2013, net income was $80.9 million, an increase of 14% compared to the same period last year.

Research and development (R&D) expenses were $27.4 million for the quarter ended September 30, 2013, or 7.7% of revenue. R&D expenses increased by 1% (a 9% increase on a constant currency basis) compared to the quarter ended September 30, 2012. R&D expenses were favorably impacted by the depreciation of the Australian dollar against the U.S. dollar.

“In the first quarter of fiscal 2014, revenue in the Americas increased by 4% over the prior year’s quarter, to $201.5 million. Revenue outside the Americas was $156.2 million, a 5% increase on a constant currency basis, over the prior year’s quarter,” said Mick Farrell, CEO, via press release. “Global revenue growth was driven primarily by sales of higher valued flow generators, like our S9 AutoSet and S9 bilevels, while mask spares and accessories did particularly well this quarter. Operating profit for the September quarter was $96.9 million, cash flow from operations was $90.4 million, while gross margin increased to 63.7%, all demonstrating excellent operating performance.”

Acknowledging a “tough competitive product cycle this quarter,” Farrell said the company had “only just released our new mask products, but we were encouraged by their early sales.”

The Quattro Air is on its way to being one of the best mask launches ever for the company, while the Swift FX Nano, which was already selling well in Europe, was just launched in the U.S. in September with good reception.

“We have a rich pipeline of products scheduled for introduction over the course of this fiscal year, providing us with plenty of opportunities for robust growth ahead,” added Farrell. “The opportunities in sleep and respiratory care remain attractive; we continue to provide our customers with the right solutions to better manage their businesses while providing high quality products to improve compliance and patient care. We are focused on continuing to improve the quality of life for patients who suffer from sleep-disordered breathing and its related co-morbidities, such as cardiology and diabetes; respiratory disorders, including chronic obstructive pulmonary disease; preventing disease progression; and saving both in-patient and out-patient costs.”

Source: ResMed

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More Research Ties Sleep Problems to Cardiac Outcomes

According to researchers at the University of Toronto, minimizing sleep disorders following coronary angioplasty is a good way to stay alive longer.

As summarized in a recent article titled “Symptoms of Disturbed Sleep Predict Major Adverse Cardiac Events After Percutaneous Coronary Intervention“, patients successfully treated with percutaneous coronary intervention (PCI), who reported the most symptoms associated with poor sleep, had a 67% incidence of heart attack—undergoing repeat vascularization, or dying within 4 years of the procedure. Just 12% who reported no sleep disturbances suffered the same fate.

Multivariate analysis revealed that each additional symptom of disturbed sleep (on a 10-symptom scale) was associated with a hazard ratio for adverse cardiac events of 1.2 (P=0.001), and that this association was largely driven by the link between sleep problems and repeat revascularization (repeat PCI hazard ratio, 1.9, P=0.003, CABG hazard ratio 1.5, P=0.001), stated researcher Steven E. Miner, MD, of the University of Toronto.

Read Abstract Here

“The absolute attributable risk is high,” the researchers wrote. “Further studies are needed to determine which sleep disorders are most associated with increased risk for cardiovascular disease and if interventions aimed at improving sleep will improve cardiac outcomes after PCI.”

MedPage reporter Salynn Boyles points out that disturbed sleep is increasingly recognized as a risk factor for cardiovascular disease (CVD). “What we don’t have is randomized trials to tell us what it is about disturbed sleep that influences cardiovascular outcomes, and most of the studies that have been done have been in low-risk populations,” .

Source: Canadian Journal of Cardiology

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UCLA Researchers: “Results Could be Deadly” for Women with Sleep Apnea

Researchers at the University of California, Los Angeles, found that the body’s autonomic responses that control blood pressure, heart rate, and sweating are weaker in people with obstructive sleep apnea, but even more diminished in women.

As reported in the UCLA Newsroom, the new study from the UCLA School of Nursing includes some stern warnings. “We now know that sleep apnea is a precursor to bigger health issues,” said Paul Macey, lead researcher of the study “Heart Rate Responses to Autonomic Challenges in Obstructive Sleep Apnea“, which appeared in the peer-reviewed journal PLOS ONE. “And for women in particular, the results could be deadly.”

Click Here to view full article

UCLA Newsroom reporter Laura Perry points out that sleep apnea affects more that 20 million adults in the U.S. “and is associated with a number of serious health consequences and early death. Women are much less likely to be diagnosed than men.”

For the study, men and women, both with and without obstructive sleep apnea, had their heart-rate responses measured during three physical tasks:

• The Valsalva maneuver: Subjects breathe out hard while the mouth is closed.

• A hand-grip challenge: Subjects squeeze hard with their hand.

• A cold pressor challenge: A subject’s right foot is put in almost-freezing cold water for a minute.

In all three tests, changes to the normal heart rate were lower and delayed in patients with obstructive sleep apnea, compared with healthy controls. The researchers found that the difference was even more pronounced in women.

“The heart-rate results for these tests show that the impact of sleep apnea, while bad in men, is more severe in women,” Macey said. “This may mean that women are more likely to develop symptoms of heart disease, as well as other consequences of poor adaptation to daily physical tasks. Early detection and treatment may be needed to protect against damage to the brain and other organs.”

The next step in the research is to see if the autonomic responses improve with treatments such as CPAP. Researchers also intend to investigate the affect of other treatments. The study was funded by the National Institutes of Health and the National Institute of Nursing Research.

Source: UCLA newsroom

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54% U.S Combat Veterans Suffer from Insomnia

Recent literature published in Current Psychiatry Reports titled “Deployment-related insomnia in military personnel and veterans”  states Insomnia is reported by 54% of the 2 million U.S. men and women who served in various combat efforts since Sept., 11, 2001, which is more than double the insomnia rate among civilian adults.

View Abstract Here

Even if insomnia may have developed prior to joining the military, it can also occur during the service period, with combat exposure, mild traumatic brain injury, irregular sleep/wake schedules or post-deployment when the soldier returns to civilian life. Soldiers who suffer from insomnia while being deployed have a greater chance of developing traumatic stress reactions such as depression and post-traumatic stress disorders, and even committing suicide, said Dr. Adam Bramoweth of the Department of Veterans Affairs Pittsburgh Healthcare System, and Dr. Anne Germain of the University of Pittsburgh School of Medicine.

Training was recently rolled out to prepare providers in the Veterans Health Administration to use cognitive behavioral treatment of insomnia. The goal is to educate 1,000 clinicians in an effort to bridge the gap between veterans who need treatment, and available providers.

“Training providers to be knowledgeable about insomnia and behavioral treatment options is a vital component to the treatment of chronic insomnia and managing its impact on other disorders,” said the researchers.

Source: News Medical

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National Data Repository for Sleep Research Takes Shape

A $7.7 million grant from the NIH to Brigham and Women’s Hospital (BWH), and Case Western Reserve University School of Medicine, will establish a national data repository of valuable sleep research.

Reports that the so-called National Sleep Research Resource (NSRR) will be a comprehensive, easily accessible, and well-annotated national repository of sleep data. The 5-year grant will make data from more than 50,000 sleep studies available to sleep researchers across the country.

“The project represents efforts to use big data in powerful and cost-effective ways, leveraging prior investments in research data collection, with a goal of enhancing clinical and translational work in human sleep medicine and physiology,” said Susan Redline, MD, MPH, associate clinical director of the Division of Sleep Medicine at BWH and principal investigator on the NSSR grant. “The resource will provide opportunities for investigators to address critical questions regarding subgroup susceptibility to sleep disorders; the impact of sleep disorders on important clinical outcomes; the role of sleep disorders as mediators in the pathogenesis of cardiopulmonary diseases; and genetic susceptibility to sleep disorders.”

“This project represents a true collaborative partnership among informaticians, data scientists, and clinical investigators,” said GQ Zhang, PhD, Division Chief of Medical Informatics and Professor of Computer Science at Case Western Reserve University. Zhang serves as the chief architect and principal investigator of NSRR.

“A national resource such as NSRR can only be achieved through innovative computer science and informatics approaches, using state-of-the-art data mapping, visualization and query tools to allow investigators to search and aggregate data across multiple studies and time points,” stated Zhang.


Source: Case Western Reserve University

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Rulemaking Reigns as Obama Signs Sleep-Related Trucking Bill

WASHINGTON, DC – While the government shutdown took center stage on Capitol Hill, President Obama quietly signed a bill ensuring that any changes in federal requirements for truck driver sleep disorders, such as sleep apnea, must come through the rulemaking process, rather than guidance to medical examiners.

As reported by, the legislative approach is a distinction with a difference. The Federal Motor Carrier Safety Administration (FMCSA) traditionally has relied on guidance, but the industry-favored rulemaking process requires more research, including a cost-benefit analysis.

According to Sean Garney, manager of safety policy at American Trucking Associations, rulemaking will require the FMCSA to estimate the number of drivers who would be affected by the rule, the percentage of crashes in which sleep apnea is a factor, and the percentage that would be affected by treatment of apnea.

Trucking industry reporter Oliver Patton reports that the agency will have to look at the cost and effectiveness of testing and treatment, as well as the “discouragement factor”–the extent to which a rule would discourage drivers from coming into the industry, or staying in it, Garney said. “There’s just a lot that they’re going to have to study in order to understand the real impacts on the industry,” he said.

ATA estimates that a sleep apnea rule will cost the industry more than $1 billion a year, which is one reason why it pushed Congress to pass the bill that Obama signed last week.


Source: ATA

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Sleep Related Trucking Legislation Takes Fast Track to Obama’s Desk

Bucking the trend toward legislative gridlock, new legislation to limit sleep apnea “guidance” has passed the House and Senate, and is now headed to the President’s desk. The bill was approved in the House by a vote of 405-0 in late September, and the Senate (also unanimously) passed it in October.

“The best part,” writes Charlie Morasch, of LandLineMag, a trucking industry publication, is that “Truckers are being hailed for their efforts to support the proposed law.”

Introduced in mid-September by Reps Larry Bucshon (R-Ind) and Dan Lipinski (D-Ill), HR3095 required the Federal Motor Carrier Safety Administration to go through its regulatory process and institute formal “rulemaking” instead of simply issuing “guidance” to physicians, drivers, and motor carriers.

As reported, the proposed Senate bill was co-sponsored by Sens Roy Blunt (R-Mo), and Mark Warner (D-Va). It aimed to “ensure that any new or revised requirement providing for the screening, testing or treatment of individuals operating commercial vehicles for sleep disorders is adopted through a rulemaking proceeding.”

“Both pieces of legislation were seen as a response to rumblings that FMCSA was preparing guidance that would urge physicians to require truckers with a Body Mass Index of 35 or greater to undergo overnight sleep exams,” writes Morasch. “Guidance – although it would carry the weight of FMCSA’s name – wouldn’t have required a public comment period or other measures common to the regulatory approval process.”

Source: Owner Operator Independent Drivers Association (OOIDA)

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