Obstructive Sleep Apnea and Cardiovascular Disease: A Perspective and Future Directions
Section snippets
Biological Pathways
There is biological plausibility to the notion that OSA leads to cardiovascular disease.
Cardiovascular Consequences
The various mechanisms discussed above lead to a number of clinical consequences that are briefly considered.
Obesity and OSA—Interacting Partners
There is no doubt, therefore, of the biological plausibility, and for some aspects definitive evidence, of the role of OSA in cardiovascular disease. However, as just discussed, this role may be dependent on the degree of obesity.
The pathways that we are describing being affected by OSA are the same pathways that are affected by obesity (see Fig 1). Moreover, obesity is a risk factor for OSA, particularly visceral adiposity.6, 7, 8, 9 Obstructive sleep apnea might, in turn, alter fat
Evidence From Epidemiologic Studies
The arguments presented would imply that individuals with OSA will have an increased risk for myocardial infarction, stroke, hypertension, and so on. This has been shown in multiple epidemiologic studies in different populations, where associations have been demonstrated (for reviews, see references 113, 114).
Although space does not permit detailed review of these studies, some points are worth noting. The 2 largest studies have been conducted in the United States—the Wisconsin Sleep Cohort
Studies on Clinical Sleep Apnea Cohorts
Another approach that has been used is to assemble large clinical cohorts of patients with OSA.130, 131, 132 Such studies can take advantage of many patients not initially accepting therapy, in the form of nasal CPAP, or becoming noncompliant with therapy.130, 131 Thus, outcomes in treated and untreated patients can be compared. These studies have largely been done in Europe.130, 131
The studies do show that subjects with untreated OSA, compared to individuals without OSA or to patients with OSA
Personalized Medicine and OSA
It is, of course, likely that certain patients with OSA at a particular level of severity will be more at risk than others to develop adverse cardiac outcomes. This is in line with the vision of personalized medicine, which is being pursued in the area of cardiovascular disease.140 Recent data from a large cohort of patients with sleep apnea assembled in Iceland—the Icelandic Sleep Apnea Cohort—support this view (see Fig 7). About half of this cohort of patients with OSA has hypertension. Many
Randomized Treatment Trials of Efficacy of Treatment of OSA on Cardiovascular Outcomes—The Holy Grail
Ultimately, if the cardiology community is to become convinced that OSA should be actively diagnosed and treated, evidence will be needed from randomized trials. The sleep field has performed randomized trials for other outcomes of OSA, having been called to action by the provocative article of Wright et al.154 Thus, the field has shown positive benefits of CPAP therapy in placebo-controlled trials in patients with severe OSA with respect to sleepiness, both subjective and objective (for
Conclusions
In this perspective we have summarized the current state of evidence as to whether OSA is a causative factor in genesis of cardiovascular disease. We have argued that this is a vital question to address because treatment of OSA may represent an important approach to reduce further cardiovascular morbidity and mortality, particularly in obese subjects in whom both OSA and cardiovascular consequences are highly prevalent.
The current evidence is highly suggestive, but there are still
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2019, Sleep MedicineCitation Excerpt :Based on cohort studies from Western countries, the prevalence of OSA is approximately 9–15% in adult women and 19–24% in adult men [2,3]. It is generally accepted that OSA increases the risk of cardiovascular diseases such as hypertension, cardiac arrhythmia, congestive heart failure, acute myocardial infarction, and stroke [4–7]. Although the underlying pathogenetic mechanisms are not fully understood, alterations in autonomic function are implicated in the development of these cardiovascular diseases in patients with OSA [8–11].
Pathogenesis of Obstructive Sleep Apnea
2019, Clinics in Chest Medicine