Impact pronostic et thérapeutique des troubles du sommeil chez des patients à risque cardiovasculaire élevé

Sleep disorders are frequent in the general population and their prevalence is higher in patients with metabolic or cardiovascular disorders, leading to repercucpapssions on quality of life and cardiovascular prognosis.Among these disorders, obstructive sleep apnea syndrome (OSA) is considered as an independent cardiovascular risk factor. The first line treatment for OSA is continuous positive airway pressure (CPAP), which improves the symptoms associated with OSA, in particular daytime sleepiness, but with effectiveness in preventing cardiovascular events remaining debated.The objectives of this thesis were on the one hand to improve the understanding of the physiopathological and clinical links between sleep disorders, including OSA, and cardiovascular diseases and on the other hand to specify the clinical and physiopathological impacts of different treatments of OSA.We provided some answers to the first objective by demonstrating that 1 / the presence of OSA was not associated with ventricular remodeling in patients with an acute myocardial infarction and that 2 / parameters indicating poor sleep, and in particular a decrease in total sleep time and the intake of drugs acting on the central nervous system, were associated with the occurrence of major cardiovascular events in patients with heart failure. Regarding the second objective, we demonstrated that an individualized 8-week exercise training program improved objectively assessed daytime sleepiness and the apnea hypopnea index in REM sleep, these two parameters being markers of the severity of OSA and being associated with cardiovascular risk.This work is part of a longer-term project that should provide some answers in order to move towards precision medicine in the definition and management of sleep-disordered breathing.Les troubles du sommeil sont fréquents dans la population générale et leur prévalence est encore plus élevée chez les patients avec des comorbidités métaboliques ou cardiovasculaires, entrainant des répercussions sur la qualité de vie et le pronostic cardiovasculaire.Parmi ces troubles, le syndrome d’apnées hypopnées obstructives du sommeil (SAHOS) est considéré comme un facteur de risque cardiovasculaire indépendant. Le traitement de référence du SAHOS est la pression positive continue (PPC) qui permet d’améliorer la symptomatologie nocturne et diurne liée au SAHOS, et notamment la somnolence diurne, mais dont l’efficacité sur la prévention des événements cardiovasculaires reste débattue.Les objectifs ce cette thèse étaient d’une part d’améliorer la compréhension des liens physiopathologiques et cliniques entre les troubles du sommeil, dont le SAHOS, et les maladies cardiovasculaires et d’autre part de préciser les impacts cliniques et physiopathologiques de différents traitements du SAHOS.Nous avons apporté des éléments de réponse au premier objectif en démontrant que 1/la présence d’un SAHOS n’était pas associée au remodelage ventriculaire chez des patients ayant présenté un infarctus du myocarde et que 2/des paramètres témoignant d’un mauvais sommeil, et notamment une diminution du temps de sommeil total et la prise de médicaments agissant sur le système nerveux central, étaient associés à la survenue d’évènements cardiovasculaires majeurs chez des patients avec une insuffisance cardiaque. Concernant le deuxième objectif, nous avons démontré qu’un réentrainement à l’effort individualisé de 8 semaines améliorait la somnolence diurne évaluée objectivement et l’index d’apnées hypopnées en sommeil paradoxal, ces deux paramètres étant des marqueurs de sévérité du SAHOS et étant associés au risque cardiovasculaire.Ces travaux s’inscrivent dans un projet de plus long terme qui doit permettre d’apporter des éléments de réponse pour évoluer pour une médecine de précision dans la définition et la prise en charge des troubles respiratoires du sommeil

La télésurveillance du patient insuffisant respiratoire chronique en France : l’opportunité d’organiser une prise en charge efficiente

International audienceThe year 2023 is marked by the officialization in French law of medical telemonitoring. Adult patients suffering from severe chronic respiratory failure (CRF) and being treated non-invasive ventilation (NIV) and/or oxygen therapy in a home setting are eligible for telemonitoring, of which the costs are to be covered by French health insurance. Telemonitoring allows a medical professional to remotely interpret the data necessary for follow-up and, if necessary, to make decisions regarding management of a given patient. Its objectives are, at the very least, to stabilize the disease through appropriate monitoring, to improve efficiency and quality of care, and to improve that patient's quality of life. The objective of this synthesis is to review the current state of remote monitoring of CRF patients by identifying, through a narrative analysis of the literature, its current benefits and limitations, and to compare present-day telemonitoring with the guidelines of the official French health authority (Haute Autorité de santé) for its nationwide application

Mise au point sur la téléréadaptation respiratoire dans la BPCO

International audienceTelerehabilitation brings together a set of rehabilitation practices applied remotely by means of information and communication technologies. Even though it has been taking on increasing importance in many health fields over 10 years, telerehabilitation had yet to find its place in pulmonary rehabilitation before 2020, when the pandemic situation impelled numerous teams to put it to work. Pilot studies on respiratory diseases, primarily COPD, along with recent data from randomized or non-randomized studies, have enhanced our understanding of "remote" practice. In this review of the literature, we will show that pulmonary telerehabilitation is feasible, safe and likely to yield short-term (and possibly longer term) effects generally similar to those achieved in the pulmonary rehabilitation programs of specialized centers, especially as regards some indicators of exercise tolerance, dyspnea or patient quality of life. However, the number of studies and patients included in these programs remains too limited in terms of modalities, duration, long-term effects, or adaptations in case of exacerbation to be the subject of recommendations. The potential of respiratory telerehabilitation justifies continuing clinical trials and experiments, which need to be coordinated with the interventions characterizing a conventional program

Formal verification of a telerehabilitation system through an abstraction and refinement approach using Uppaal

International audienceFormal methods are proven techniques that provide a rigorous mathematical basis to software development. In particular, they allow the quality of development to be effectively improved by making accurate and explicit modelling, so that anomalies like ambiguities and incompleteness are identified in the early phases of the software development process. Semi-formal UML models and formal Timed Automata models are used to design a telerehabilitation system through a practical approach based on abstraction and refinement. The formal verification of expected properties of the system is performed by the Uppaal tool. The motivation of this work is threefold: (i) showing the usefulness of formal methods to satisfy the validation needs of a medical telerehabilitation system; (ii) demonstrating our approach of system analysis through refinements to guide the development of a complex system; and (iii) highlighting, from a real-life experience, the usefulness of models to involve the stakeholders all along the design of a system, from requirements to detailed specifications

Assessment by Patients of a Connected System for Telerehabilitation: Lessons Learned from a Randomized Qualitative Study.

International audienceThis poster presents the design of a connected system for telerehabilitation for patients with obesity and the assessment of the system through a randomized qualitative study on a sample of 15 patients. The patients expressed positive motivation but negatively assessed (as a deficiency) the system operation. All patients found that the system was neither intuitive nor easy to use

Standardization of the assessment process within telerehabilitation in chronic diseases: a scoping meta-review

International audienceBackground Telerehabilitation (TR) interventions are receiving increasing attention. They have been evaluated in various scientific areas through systematic reviews. However, there is a lack of data on how to standardize assessment and report on their domains to guide researchers across studies and bring together the best evidence to assess TR for chronic diseases. Aims and objectives The aim of this study was to identify domains of assessment in TR and to qualitatively and quantitatively analyze how and when they are examined to gain an overview of assessment in chronic disease. Methods A scoping meta-review was carried out on 9 databases and gray literature from 2009 to 2019. The keyword search strategy was based on "telerehabilitation ", “evaluation" , “chronic disease" and their synonyms. All articles were subjected to qualitative analysis using the Health Technology Assessment (HTA) Core Model prior to further analysis and narrative synthesis. Results Among the 7412 identified articles, 80 studies met the inclusion criteria and addressed at least one of the noncommunicable diseases (NCD) categories of cardiovascular disease (cardiovascular accidents), cancer, chronic respiratory disease, diabetes, and obesity. Regarding the domains of assessment, the most frequently occurring were “ social aspect” ( n = 63, 79%) (e.g., effects on behavioral changes) and “ clinical efficacy” ( n = 53, 66%), and the least frequently occurring was “safety aspects” ( n = 2, 3%). We also identified the phases of TR in which the assessment was conducted and found that it most commonly occurred in the pilot study and randomized trial phases and least commonly occurred in the design , pretest , and post-implementation phases. Conclusions Through the HTA model, this scoping meta-review highlighted 10 assessment domains which have not been studied with the same degree of interest in the recent literature. We showed that each of these assessment domains could appear at different phases of TR development and proposed a new cross-disciplinary and comprehensive method for assessing TR interventions. Future studies will benefit from approaches that leverage the best evidence regarding the assessment of TR, and it will be interesting to extend this assessment framework to other chronic diseases

Effects of an individualized exercise training program on severity markers of obstructive sleep apnea syndrome: a randomised controlled trial

International audienceObjective: Obstructive sleep apnea (OSA) is a high prevalent disorder with severe consequences including sleepiness, metabolic, and cardiovascular disorders. The aim of this study was to assess the effect of an individualized exercise-training (IET) program with educational sessions vs educational sessions alone on severity markers of OSA over an eight-week duration.Methods: This was a randomised, controlled, parallel-design study. In sum, 64 patients with moderate-to-severe OSA (apnea-hypopnea index AHI 15–45/hour), low physical activity level (Voorrips<9), body-mass index (BMI) <40 kg/m2 were included in intervention group (IG) or control group (CG), and 54 patients finished the study. All underwent polysomnography (PSG), multiple sleep latency test (MSLT), constant workload exercise test, blood samples and fulfilled questionnaires twice. The primary endpoint was the change in apnea-hypopnea (AHI) at eight weeks from baseline. Main secondary endpoints were daytime sleepiness assessed by questionnaire and objective tests.Results: No significant between-group differences were found for changes in AHI. A reduction in AHI was found in IG only (p = 0.005). Compared to CG, exercise training leads to a greater decrease in AHI during REM sleep (p = 0.0004), with a significant increase in mean daytime sleep latency (p = 0.02). Between-group differences were significant for weight reduction, severity of fatigue, insomnia and depressive symptoms with trend for sleepiness symptoms.Conclusions: In adult patients with moderate-to-severe OSA, IET did not decrease AHI compared to the control group but improved markers of severity of OSA, in particular AHI in rapid eye movement (REM) sleep and objective daytime sleepiness. Adding personalized exercise training to the management of patients with OSA should be considered

Prognostic Impact of Sleep Patterns and Related-Drugs in Patients with Heart Failure

International audienceSleep disturbances are frequent among patients with heart failure (HF). We hypothesized that self-reported sleep disturbances are associated with a poor prognosis in patients with HF. A longitudinal study of 119 patients with HF was carried out to assess the association between sleep disturbances and the occurrence of major cardiovascular events (MACE). All patients with HF completed self-administered questionnaires on sleepiness, fatigue, insomnia, quality of sleep, sleep patterns, anxiety and depressive symptoms, and central nervous system (CNS) drugs intake. Patients were followed for a median of 888 days. Cox models were used to estimate the risk of MACE associated with baseline sleep characteristics. After adjustment for age, the risk of a future MACE increased with CNS drugs intake, sleep quality and insomnia scores as well with increased sleep latency, decreased sleep efficiency and total sleep time. However, after adjustment for left ventricular ejection fraction and hypercholesterolemia the HR failed to be significant except for CNS drugs and total sleep time. CNS drugs intake and decreased total sleep time were independently associated with an increased risk of MACE in patients with HF. Routine assessment of self-reported sleep disturbances should be considered to prevent the natural progression of HF

Long term (3 years) weight loss after low intensity endurance training targeted at the level of maximal muscular lipid oxidation

International audienceAmong various strategies of exercise intensification proposed for the management of obesity and type 2 diabetes, endurance training remains a well recognized procedure. When targeted with exercise calorimetry at levels where lipid oxidation is maximal (LIPOXmax), it has been shown to improve mitochondrial respiration, blood glucose control and blood lipids, low grade inflammation and body composition, even at low weekly volume. We investigated in this study its long term effects over 3 years (3x45 min/week) compared to low fat diet without exercise (LFD) and a control group without any exercise or diet (C). 88 subjects that continued LIPOXmax training more than 1 year (23 men, 65 women, age=20-85 years, body mass index =23-48 kg/m2) were compared to two matched groups (C and LFD). While C gained weight over this period, LFD and LIPOXmax group lose weight. Weight loss at 1 year was the same in exercise and diet group, but at 2 years and even more at 3 years there was a gradual weight regain in LFD so that results were better (p<0.01) in the exercise group who maintained weight loss in 80% of subjects. Average weight loss was -2,95 ± 0,37 kg after 3 months, -4,56 ± 0,68 kg after 1 year, -5,31 ± 1,26 kg at 2 years and -8,49 ± 2,39 kg at 3 years. The level at which LIPOXmax occurs is a predictor of weight loss at 1 year (r=-0,346 p<0,001) but not at 2 and 3 years. Weight loss at 3 months is a predictor of weight loss at 1 year (r=0,523 p<0,001) but not at 2 and 3 years. At 1 year subjects with LIPOX max in the lower quartile (<35% VO2max n=23) lose less weight than the others (-2.3 ± 0.98 vs -5.4 ± 0.83 p=0,05) but this difference vanishes over time. This study shows that this low intensity exercise training maintains its weight-reducing effect 3 years while diet is no longer efficient, and that this effect is initially related to muscular ability to oxidize lipids but that metabolic and behavioral adaptations have been further developed and contribute to a long lasting effect