Obstructive sleep apnea (OSA) is characterized by recurrent complete and partial upper airway obstructive events, resulting in intermittent hypoxemia, autonomic fluctuation, and sleep fragmentation. ...Approximately 34% and 17% of middle-aged men and women, respectively, meet the diagnostic criteria for OSA. Sleep disturbances are common and underdiagnosed among middle-aged and older adults, and the prevalence varies by race/ethnicity, sex, and obesity status. OSA prevalence is as high as 40% to 80% in patients with hypertension, heart failure, coronary artery disease, pulmonary hypertension, atrial fibrillation, and stroke. Despite its high prevalence in patients with heart disease and the vulnerability of cardiac patients to OSA-related stressors and adverse cardiovascular outcomes, OSA is often underrecognized and undertreated in cardiovascular practice. We recommend screening for OSA in patients with resistant/poorly controlled hypertension, pulmonary hypertension, and recurrent atrial fibrillation after either cardioversion or ablation. In patients with New York Heart Association class II to IV heart failure and suspicion of sleep-disordered breathing or excessive daytime sleepiness, a formal sleep assessment is reasonable. In patients with tachy-brady syndrome or ventricular tachycardia or survivors of sudden cardiac death in whom sleep apnea is suspected after a comprehensive sleep assessment, evaluation for sleep apnea should be considered. After stroke, clinical equipoise exists with respect to screening and treatment. Patients with nocturnally occurring angina, myocardial infarction, arrhythmias, or appropriate shocks from implanted cardioverter-defibrillators may be especially likely to have comorbid sleep apnea. All patients with OSA should be considered for treatment, including behavioral modifications and weight loss as indicated. Continuous positive airway pressure should be offered to patients with severe OSA, whereas oral appliances can be considered for those with mild to moderate OSA or for continuous positive airway pressure-intolerant patients. Follow-up sleep testing should be performed to assess the effectiveness of treatment.
Sleep apnea and stroke McDermott, Mollie; Brown, Devin L
Current opinion in neurology,
02/2020, Letnik:
33, Številka:
1
Journal Article
Recenzirano
Stroke and sleep apnea are highly prevalent conditions with a physiologically plausible bidirectional relationship. This review addresses prestroke sleep apnea, wake-up stroke and sleep apnea, and ...poststroke sleep apnea, with an attempt to highlight research published in the last 18 months.
Sleep apnea is highly prevalent poststroke. Poststroke sleep apnea is associated with worse poststroke functional and cognitive outcomes and a higher risk of recurrent stroke. Physiologic tests are needed to diagnose sleep apnea in poststroke patients as sleep apnea questionnaires do not perform well in this population. The role of CPAP in poststroke management is not yet well established.
Sleep apnea is a well established independent risk factor for stroke that confers an approximately two-fold increased risk of incident stroke. Sleep apnea is highly prevalent poststroke and is associated with worse outcomes after stroke. Sleep apnea is an attractive target for research addressing secondary stroke prevention and recovery.
Intracerebral haemorrhage and small vessel ischaemic stroke (SVS) are the most acute manifestations of cerebral small vessel disease, with no established preventive approaches beyond hypertension ...management. Combined genome-wide association study (GWAS) of these two correlated diseases may improve statistical power to detect novel genetic factors for cerebral small vessel disease, elucidating underlying disease mechanisms that may form the basis for future treatments. Because intracerebral haemorrhage location is an adequate surrogate for distinct histopathological variants of cerebral small vessel disease (lobar for cerebral amyloid angiopathy and non-lobar for arteriolosclerosis), we performed GWAS of intracerebral haemorrhage by location in 1813 subjects (755 lobar and 1005 non-lobar) and 1711 stroke-free control subjects. Intracerebral haemorrhage GWAS results by location were meta-analysed with GWAS results for SVS from MEGASTROKE, using 'Multi-Trait Analysis of GWAS' (MTAG) to integrate summary data across traits and generate combined effect estimates. After combining intracerebral haemorrhage and SVS datasets, our sample size included 241 024 participants (6255 intracerebral haemorrhage or SVS cases and 233 058 control subjects). Genome-wide significant associations were observed for non-lobar intracerebral haemorrhage enhanced by SVS with rs2758605 MTAG P-value (P) = 2.6 × 10-8 at 1q22; rs72932727 (P = 1.7 × 10-8) at 2q33; and rs9515201 (P = 5.3 × 10-10) at 13q34. In the GTEx gene expression library, rs2758605 (1q22), rs72932727 (2q33) and rs9515201 (13q34) are significant cis-eQTLs for PMF1 (P = 1 × 10-4 in tibial nerve), NBEAL1, FAM117B and CARF (P < 2.1 × 10-7 in arteries) and COL4A2 and COL4A1 (P < 0.01 in brain putamen), respectively. Leveraging S-PrediXcan for gene-based association testing with the predicted expression models in tissues related with nerve, artery, and non-lobar brain, we found that experiment-wide significant (P < 8.5 × 10-7) associations at three genes at 2q33 including NBEAL1, FAM117B and WDR12 and genome-wide significant associations at two genes including ICA1L at 2q33 and ZCCHC14 at 16q24. Brain cell-type specific expression profiling libraries reveal that SEMA4A, SLC25A44 and PMF1 at 1q22 and COL4A1 and COL4A2 at 13q34 were mainly expressed in endothelial cells, while the genes at 2q33 (FAM117B, CARF and NBEAL1) were expressed in various cell types including astrocytes, oligodendrocytes and neurons. Our cross-phenotype genetic study of intracerebral haemorrhage and SVS demonstrates novel genome-wide associations for non-lobar intracerebral haemorrhage at 2q33 and 13q34. Our replication of the 1q22 locus previous seen in traditional GWAS of intracerebral haemorrhage, as well as the rediscovery of 13q34, which had previously been reported in candidate gene studies with other cerebral small vessel disease-related traits strengthens the credibility of applying this novel genome-wide approach across intracerebral haemorrhage and SVS.
Objective
To examine the association between sleep‐disordered breathing and stroke outcomes, and determine the contribution of sleep‐disordered breathing to outcome disparities in Mexican Americans.
...Methods
Ischemic stroke patients (n = 995), identified from the population‐based Brain Attack Surveillance in Corpus Christi Project (2010–2015), were offered participation in a sleep‐disordered breathing study including a home sleep apnea test (ApneaLink Plus). Sleep‐disordered breathing (respiratory event index ≥10) was determined soon after stroke. Neurologic, functional, cognitive, and quality of life outcomes were assessed at 90 days poststroke. Regression models were used to assess associations between sleep‐disordered breathing and outcomes, adjusted for sociodemographics, prestroke function and cognition, health‐risk behaviors, stroke severity, and vascular risk factors.
Results
Median age was 67 years (interquartile range IQR = 59–78); 62.1% were Mexican American. Median respiratory event index was 14 (IQR = 6–25); 62.8% had sleep‐disordered breathing. Sleep‐disordered breathing was associated with worse functional outcome (mean difference in activities of daily living/instrumental activities of daily living score = 0.15, 95% confidence interval CI = 0.01–0.28) and cognitive outcome (mean difference in modified Mini‐Mental State Examination = −2.66, 95% CI = −4.85 to −0.47) but not neurologic or quality of life outcomes. Sleep‐disordered breathing accounted for 9 to 10% of ethnic differences in functional and cognitive outcome and was associated with cognitive outcome more strongly for Mexican Americans (β = −3.97, 95% CI = −6.63 to −1.31) than non‐Hispanic whites (β = −0.40, 95% CI = −4.18 to 3.39, p‐interaction = 0.15).
Interpretation
Sleep‐disordered breathing is associated with worse functional and cognitive function at 90 days poststroke. These outcomes are reasonable endpoints for future trials of sleep‐disordered breathing treatment in stroke. If effective, sleep‐disordered breathing treatment may somewhat lessen ethnic stroke outcome disparities. ANN NEUROL 2019;86:241–250
Sleep disorders and the risk of stroke McDermott, Mollie; Brown, Devin L.; Chervin, Ronald D.
Expert review of neurotherapeutics,
07/2018, Letnik:
18, Številka:
7
Journal Article
Recenzirano
Odprti dostop
Introduction: Stroke is a major cause of disability and death in the United States and across the world, and the incidence and prevalence of stroke are expected to rise significantly due to an aging ...population. Obstructive sleep apnea, an established independent risk factor for stroke, is a highly prevalent disease that is estimated to double the risk of stroke. It remains uncertain whether non-apnea sleep disorders increase the risk of stroke.
Areas covered: This paper reviews the literature describing the association between incident stroke and sleep apnea, rapid eye movement sleep behavior disorder, restless legs syndrome, periodic limb movements of sleep, insomnia, and shift work.
Expert commentary: Trials of continuous positive airway pressure for stroke prevention in sleep apnea patients have been largely disappointing, but additional trials that target populations not yet optimally studied are needed. Self-reported short and long sleep duration may be associated with incident stroke. However, abnormal sleep duration may be a marker of chronic disease, which may itself be associated with incident stroke. The relationship between non-apnea sleep disorders and incident stroke deserves further attention. Identification of specific non-apnea sleep disorders or sleep problems that convey an increased risk for stroke may provide novel targets for stroke prevention.
Few randomized controlled trials have evaluated the effectiveness of continuous positive airway pressure (CPAP) in reducing recurrent vascular events and mortality in poststroke obstructive sleep ...apnea (OSA). To date, results have been mixed, most studies were underpowered and definitive conclusions are not available. Using lessons learned from prior negative trials in stroke, we reappraise prior randomized controlled trials that examined the use of CPAP in treating poststroke OSA and propose the following considerations: (1) Intervention-based changes, such as ensuring that patients are using CPAP for at least 4 hours per night (eg, through use of improvements in CPAP technology that make it easier for patients to use), as well as considering alternative treatment strategies for poststroke OSA; (2) Population-based changes (ie, including stroke patients with severe and symptomatic OSA and CPAP noncompliers); and (3) Changes to timing of intervention and follow-up (ie, early initiation of CPAP therapy within the first 48 hours of stroke and long-term follow-up calculated in accordance with sample size to ensure adequate power). Given the burden of vascular morbidity and mortality in stroke patients with OSA, there is a strong need to learn from past negative trials and explore innovative stroke prevention strategies to improve stroke-free survival.
Objective: We examined clinical trial knowledge and attitudes, and their relationship with willingness to participate in COVID-19 vaccine trials, and willingness to accept a COVID-19 vaccine among ...college students. Participants: 331 undergraduates: mean age 25; 72% women; and 78% white. Methods: We administered an online, anonymous survey to undergraduate students in July, 2020, during the COVID-19 pandemic. Results: The mean clinical trial knowledge score was 65% (SD = 16) correct. The mean attitudes toward clinical trials score (1 most negative: 5 most positive) was 3.3 (SD = 0.5). Attitudes toward clinical trials were associated with likelihood of COVID-19 trial participation (positive 76% vs. negative 35%, p = 0.001) and a trend toward likelihood of accepting a COVID-19 vaccine if available (positive 89% vs. negative 67%, p = 0.066). Conclusions: General clinical trial knowledge and attitudes appear to be important targets for educational interventions. Furthermore, fostering positive attitudes may lead to improved COVID-19 trial participation and vaccine uptake.
BACKGROUND AND PURPOSE—Limited data are available about the relationship between sleep-disordered breathing (SDB) and recurrent stroke and mortality, especially from population-based studies, large ...samples, or ethnically diverse populations.
METHODS—In the BASIC project (Brain Attack Surveillance in Corpus Christ), we identified patients with ischemic stroke (2010–2015). Subjects were offered screening for SDB with the ApneaLink Plus device, from which a respiratory event index (REI) score ≥10 defined SDB. Demographics and baseline characteristics were determined from chart review and interview. Recurrent ischemic stroke was identified through active and passive surveillance. Cause-specific proportional hazards models were used to assess the association between REI (modeled linearly) and ischemic stroke recurrence (as the event of interest), and all-cause poststroke mortality, adjusted for multiple potential confounders.
RESULTS—Among 842 subjects, the median age was 65 (interquartile range, 57–76), 47% were female, and 58% were Mexican American. The median REI score was 14 (interquartile range, 6–26); 63% had SDB. SDB was associated with male sex, Mexican American ethnicity, being insured, nonsmoking status, diabetes mellitus, hypertension, lower educational attainment, and higher body mass index. Among Mexican American and non-Hispanic whites, 85 (11%) ischemic recurrent strokes and 104 (13%) deaths occurred, with a median follow-up time of 591 days. In fully adjusted models, REI was associated with recurrent ischemic stroke (hazard ratio, 1.02 hazard ratio for one-unit higher REI score, 95% CI, 1.01–1.03), but not with mortality alone (hazard ratio, 1.00 95% CI, 0.99–1.02).
CONCLUSIONS—Results from this large population-based study show that SDB is associated with recurrent ischemic stroke, but not mortality. SDB may therefore represent an important modifiable risk factor for poor stroke outcomes.
BACKGROUND AND PURPOSE—Our objective was to identify factors that contribute to or modify the sex difference in poststroke functional outcome.
METHODS—Ischemic strokes (n=439) were identified from ...the Brain Attack Surveillance in Corpus Christi (BASIC) Project (2008–2011). Data were ascertained from interviews (baseline and 90 days post stroke) and medical records. Functional outcome was measured as an average of 22 activities of daily living (ADL)/instrumental ADL items (range, 1–4; higher scores worse function). Tobit regression was used to estimate sex differences and to identify confounding and modifying factors.
RESULTS—Fifty-one percent were women. Median age was 71 (interquartile range, 59–80) years in women and 64 (interquartile range, 56–77) years in men. Median ADL/instrumental ADL score at 90 days was 2.7 (interquartile range, 1.8–3.6) in women and 2.0 (interquartile range, 1.3–3.1) in men (P<0.01); this difference remained after age-adjustment (P<0.001). Factors contributing to higher ADL/instrumental ADL scores in women included prestroke function, marital status, prestroke cognition, nursing home residence, stroke severity, history of stroke/transient ischemic attack, and body mass index; prestroke function was the largest contributor. Stroke severity modified the sex difference in outcome such that differences were apparent for mild to moderate but not severe strokes. After adjustment, women still had significantly worse functional outcome than men.
CONCLUSIONS—These findings yield insight into possible strategies and subgroups to target to reduce the sex disparity in stroke outcome; demographics and prestroke and clinical factors explained only 41% of the sex difference in stroke outcome highlighting the need for future research to identify modifiable factors that contribute to sex differences.
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