Nycturie, un facteur prédictif indépendant d hypertension artérielle prévalente chez les patients souffrant d un syndrome d apnée obstructive du sommeil (une étude de cohorte prospective nationale)

Contexte : La nycturie, un symptôme fréquent dans le syndrome d apnée obstructive du sommeil (SAOS) est associée, dans la population générale, à une augmentation du risque d hypertension artérielle (HTA) et de mortalité. Le rôle de la nycturie dans l HTA dans le SAOS n a pas été étudié. Objectifs : L objectif principal de l étude était de déterminer si dans une population de patients souffrant d un SAOS, la nycturie était prédictive de l existence d une HTA prévalente après ajustement des facteurs confondants. Méthodes : Les patients SAOS participant à la cohorte nationale prospective de l OSFP (Observatoire Sommeil de la Fédération Française de Pneumologie) ont été inclus. Une analyse multivariée des données anthropométriques, des co-morbidités ainsi que les données relatives au SAS (dont la nycturie) a été réalisée afin de caractériser les variables associées à une HTA prévalente. Résultats : 22674 patients SAOS ont été inclus, dont 11332 patients hypertendus. La prévalence de l HTA chez les patients SAOS est 1.3 fois plus élevée chez les patients présentant une nycturie, 61.45% des patients hypertendus ont une nycturie versus 46.52% des patients non hypertendus (p<0.001). De plus, il existe une relation significative entre l HTA et le degré de sévérité de la nycturie, indépendamment de l âge : 1 miction nocturne versus 0 : OR=1.284 (IC95%=1.184;1.393), 2 mictions nocturnes versus 0 : OR=1.270 (IC95%=1.175;1.372), 3 mictions nocturnes versus 0 : OR=1.422 (IC95%=1.293;1.565) et 4 mictions nocturnes versus 0 : OR=1.575 (IC95%=1.394;1.781). Cette corrélation est encore plus marquée chez les patients âgés de plus de 64 ans. Par ailleurs, les autres facteurs associés à une HTA prévalente sont l âge, un IMC élevé et les co-morbidités cardio-vasculaires (coronaropathie, arythmie, accident vasculaire cérébral, diabète et dyslipidémie). Conclusions : La nycturie est donc prédictive d une HTA prévalente chez les patients SAOS. Cette relation est retrouvée quelque soit l âge, avec un profil dose-réponse . La résolution de la nycturie après traitement par Pression Positive Continue (PPC) pourrait être un résultat important à prendre en compte dans la réponse de l HTA à la PPC et du risque d évènements cardio-vasculaire à long terme.Importance: Nocturia, a common complaint in Obstructive Sleep Apnea (OSA) patients is linked, in the general population, to an increased risk of hypertension and mortality. The specific role of nocturia in OSA-related hypertension has not been studied. Objective: To determine whether nocturia is an independent predictor for prevalent hypertension after adjustment for confounders in a national OSA registry. Design, Settings and Participants: We analyzed data from a national prospective clinical cohort of obstructive sleep apnea patients participating in the French national prospective registry (Observatoire Sommeil de la Federation de Pneumologie). Anthropometric data, medical history, co-morbidities, OSA severity and number of voids/night were included in multivariate analysis to determine the independent variables associated with prevalent hypertension. Results: 22,674 OSA patients were included, 11,332 (49.98%) were hypertensive. The prevalence of hypertension among OSA patients was about 1.3 times higher in patients suffering from nocturia, with a prevalence of nocturia of 61.45% versus 46.52% in hypertensive and in non-hypertensive OSA patients respectively (p<0.001). Moreover, there was a significant positive relationship between prevalent hypertension and the severity of nocturia: 1 void/night versus 0: OR=1.284 (95%CI=1.184; 1.393), 2 voids/night versus 0: OR=1.270 (CI95%=1.175; 1.372), 3 voids/night versus 0: OR=1.422 (95%CI=1.293; 1.565) and 4 voids/night versus 0: OR=1.575 (95%CI=1.394; 1.781). The strength of the association was enhanced for OSA patients over the age of 64 years. Morever, prevalent hypertension was associated with being older, a higher BMI, cardio-vascular co-morbidities (coronary heart disease, arrhythmias, stroke, diabetes and dyslipidemia). Conclusion and Relevance: Nocturia is a strong independent predictor of prevalent hypertension in OSA patients. This association exhibited a dose-response relationship and was found for all age strata. The resolution of nocturia after continuous positive airway pressure (CPAP) treatment might be an important outcome to consider for the response of blood pressure to CPAP therapy and the risk of long term cardiovascular adverse events.GRENOBLE1-BU Médecine pharm. (385162101) / SudocSudocFranceF

Comment j’explore une bronchopneumopathie chronique obstructive ?

International audienceLa bronchopneumopathie chronique obstructive (BPCO) est une maladie fréquente que l’on peut prévenir et traiter, qui est caractérisée par des symptômes respiratoires persistants et un trouble ventilatoire obstructif dû à des lésions des voies aériennes (bronchite chronique et/ou du tissu alvéolaire (emphysème), en général en relation avec une exposition significative à des particules ou à des gaz toxiques, selon la définition mise à jour par les recommandations internationales [...

Prevalence and Factors Contributing to Daytime and Nocturnal Hypoxemia in Chronic Heart Failure Patients

International audienceBackground: Despite clinical optimization, many chronic heart failure (CHF) patients remain symptomatic with dyspnea and poor quality of life. Study Objective: While oxygen therapy is prescribed in severe cases, the actual prevalence of different patterns of hypoxemia is unknown. Methods: We analyzed 183 stable CHF patients with optimized medical treatment in the “MARS” database. The patients underwent cardiorespiratory sleep recording and complete daytime pulmonary function tests including arterial blood gases. Results: This prospective cohort was predominately male (86.3%) with a mean age of 67.3 years (59.3; 75.7) and a mean BMI of 26.7 kg/m2 (23.7; 31.1). The patients were mainly in NYHA classes II and III with a mean left ventricular ejection fraction of 38%. 102 (55.61%) patients had ischemic cardiomyopathy with multiple comorbidities, and 64 (35.06%) had airflow obstruction. 8 (4.37%) patients had hypoxemia both day and night, and 151 (82.5%) had nocturnal hypoxemia only. All but 3 patients had sleep-disordered breathing (SDB), and either obstructive (59%) or central sleep apnea (39%) with a mean apnea-hypopnea index of 29.59/h (16.48; 48.27), an oxygen desaturation index of 27.09/h (14.09; 45.25), time below 90% saturation of 18 min (2; 64), and a mean nocturnal saturation of 93% (92; 94). Univariate analysis found nocturnal hypoxemia was associated with higher BMI and NT-proBNP levels. In multivariate analysis, only sleep apnea severity (p &#x3c; 0.0001) and diurnal PaO2 remained significant. Conclusion: Most stable CHF patients suffer from nocturnal hypoxemia, while daytime hypoxemia is relatively rare. The degree of nocturnal hypoxemia depends on the severity of SDB. Hypoxemia phenotyping and severity could help better evaluate the need for appropriate therapy in CHF patients

Contribution of obstructive sleep apnoea to arterial stiffness: a meta-analysis using individual patient data

International audienceBackground Arterial stiffness, measured by pulse wave velocity (PWV), is a strong independent predictor of late cardiovascular events and mortality. It is recognised that obstructive sleep apnoea (OSA) is associated with cardiovascular comorbidities and mortality. Although previous meta-analyses concluded that PWV is elevated in OSA, we feel that an individual patient data analysis from nine relatively homogeneous studies could help answer: to what extent does OSA drive arterial stiffness?Methods Individual data from well-characterised patients referred for suspicion of OSA, included in nine studies in which carotid–femoral PWV was measured using a Complior device, were merged for an individual patient data meta-analysis.Results 893 subjects were included (age: 56±11 (mean±SD), 72% men, 84% with confirmed OSA). Body Mass Index varied from 15 to 81 kg/m 2 (30±7 kg/m 2 ). PWV ranged from 5.3 to 20.5 m/s (10.4±2.3 m/s). In univariate analysis, log(PWV) was strongly related to age, gender, systolic blood pressure, presence of type 2 diabetes (all p<0.01) as well as to dyslipidaemia (p=0.03) and an Epworth Sleepiness Scale score ≥9 (p=0.04), whereas it was not related to obesity (p=0.54), a severe Apnoea–Hypopnoea Index (p=0.14), mean nocturnal saturation (p=0.33) or sleep time with oxygen saturation below 90% (p=0.47). In multivariable analysis, PWV was independently associated with age, systolic blood pressure and diabetes (all p<0.01), whereas severe OSA was not significantly associated with PWV.Conclusion Our individual patient meta-analysis showed that elevated arterial stiffness in patients with OSA is driven by conventional cardiovascular risk factors rather than apnoea parameters

Reduction in sympathetic tone in patients with obstructive sleep apnoea: is fixed CPAP more effective than APAP? A randomised, parallel trial protocol

International audienceIntroduction Obstructive sleep apnoea (OSA) is a prevalent disease associated with cardiovascular events. Hypertension is one of the major intermediary mechanisms leading to long-term cardiovascular adverse events. Intermittent hypoxia and hypercapnia associated with nocturnal respiratory events stimulate chemoreflexes, resulting in sympathetic overactivity and blood pressure (BP) elevation. Continuous positive airway pressure (CPAP) is the primary treatment for OSA and induces a small but significant reduction in BP. The use of auto-adjusting positive airway pressure (APAP) has increased in the last years and studies showed different ranges of BP reduction when comparing both modalities. However, the pathophysiological mechanisms implicated are not fully elucidated. Variations in pressure through the night inherent to APAP may induce persistent respiratory efforts and sleep fragmentation that might impair sympathovagal balance during sleep and result in smaller decreases in BP. Therefore, this double-blind randomised controlled trial aims to compare muscle sympathetic nerve activity (MSNA) assessed by microneurography (reference method for measuring sympathetic activity) after 1 month of APAP versus fixed CPAP in treatment-naive OSA patients. This present manuscript describes the design of our study, no results are presented herein. and is registered under the below reference number. Methods and analysis Adult subjects with newly diagnosed OSA (Apnoea–Hypopnoea Index >20/hour) will be randomised for treatment with APAP or fixed CPAP. Measurements of sympathetic activity by MSNA, heart rate variability and catecholamines will be obtained at baseline and after 30 days. The primary composite outcome will be the change in sympathetic tone measured by MSNA in bursts/min and bursts/100 heartbeats. Sample size calculation was performed with bilateral assumption. We will use the Student’s t-test to compare changes in sympathetic tone between groups. Ethics and dissemination The protocol was approved by The French Regional Ethics Committee. The study started in March 2018 with primary completion expected to March 2019. Dissemination plans of the results include presentations at conferences and publication in peer-reviewed journals. Trial registration number NCT03428516 ; Pre-results

Sleep-disordered breathing and ventilatory chemosensitivity in first ischaemic stroke patients: a prospective cohort study

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Computed Tomography Registration-Derived Regional Ventilation Indices Compared to Global Lung Function Parameters in Patients With COPD

International audienceCT registration-derived indices provide data on regional lung functional changes in COPD. However, because unlike spirometry which involves dynamic maximal breathing maneuvers, CT-based functional parameters are assessed between two static breathholds, it is not clear how regional and global lung function parameters relate to each other. We assessed the relationship between CT-density change (dHU), specific volume change (dsV), and regional lung tissue deformation (J) with global spirometric and plethysmographic parameters, gas exchange, exercise capacity, dyspnoea, and disease stage in a prospective cohort study in 102 COPD patients. There were positive correlations of dHU, dsV, and J with spirometric variables, DLCO and gas exchange, 6-min walking distance, and negative correlations with plethysmographic lung volumes and indices of trapping and lung distension as well as GOLD stage. Stepwise regression identified FEV1/FVC (standardized β = 0.429, p < 0.0001), RV/ TLC (β = −0.37, p < 0.0001), and BMI (β = 0.27, p=<0.001) as the strongest predictors of CT intensity-based metrics dHU, with similar findings for dsV, while FEV1/FVC (β = 0.32, p=<0.001) and RV/TLC (β = −0.48, p=<0.0001) were identified as those for J. These data suggest that regional lung function is related to two major pathophysiological processes involved in global lung function deterioration in COPD: chronic airflow obstruction and gas trapping, with an additional contribution of nutritional status, which in turn determines respiratory muscle strength. Our data confirm previous findings in the literature, suggesting the potential of CT image-based regional lung function metrics as the biomarkers of disease severity and provide mechanistic insight into the interpretation of regional lung function indices in patients with COPD

Interface Type on Noninvasive Ventilation Efficacy in Patients With Neuromuscular Disease : A Randomized Cross-Over Trial

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Impacto del tipo de mascarilla en la eficacia de la ventilación no invasiva en pacientes con enfermedad neuromuscular: un ensayo clínico aleatorizado cruzado

International audienceBackground and objective: Around 25% of patients with neuro-muscular diseases (NMD) are treated by home noninvasive ventilation (NIV) through an oronasal mask. However, there is growing evidence that nasal masks require lower NIV pressures and result in fewer residual obstructive events. We hypothesized that nasal masks would improve efficacy and reduce side effects compared to oronasal masks in this population. Methods: open label, cross-over, randomized, study in 2 tertiary care hospitals. Patients with NMD treated by home NIV were randomized for one-week periods to nasal and oronasal interfaces respectively (cross-over). At the end of each period, nocturnal polygraphy (monitoring mouth opening) under NIV, synchronized with transcutaneous partial pressure in CO2 (tcCO2) was performed. Data were collected from the NIV built-in software and NIV side-effects were collected. Intention-to-treat and per protocol analyses were performed. The primary outcome was mean nocturnal SpO2. The secondary outcomes were: percentage of sleep with SpO2 &lt; 90%, oxygen desaturation index (ODI), mean tcCO2, mean duration of mouth opening during sleep, level of non-intentional leaks and side-effects. Results: Thirty patients with NMD were included. There were no between-group differences for either the primary or secondary outcomes. Post hoc comparisons showed that changing between interfaces reduced NIV efficacy: mean nocturnal SpO2 (p = 0.04), ODI (p = 0.01), mean tcCO2 (p = 0.048), side-effects (p = 0.008). Conclusion: Nasal masks did not improve NIV efficacy or reduce side effects compared to oronasal masks in patients with NMD treated by home NIV. The efficacy of NIV is reduced during the transition to another interface, requiring close monitoring. Registration number: NCT03458507