Utility of polygraphic studies for sleep apnea screening in the setting of tertiary care hypertension outpatient clinic

Background: Prevalence of obstructive sleep apnea (OSA) in patients with hypertension outnumbers the prevalence reported in the general population. Concurrently, majority of patients remain undiagnosed. Given the fact that untreated OSA contributes to ineffective hypotensive treatment, and higher rate of complications is ascribed to hypertension, early OSA diagnosis and its elimination constitutes one of the key clinical goals. Polysomnography comprises a golden standard in sleep apnea diagnosis, however it is a time-consuming and expensive procedure which requires hospitalization. Therefore, we assessed the utility of simplified polygraphic (PG) studies in the OSA screening of patients with hypertension requiring regular tertiary care. Material and methods: The study was conducted in the Outpatient Tertiary Care Clinic of the Medical University Hospital of Gdansk. We enrolled consecutive patients regardless of OSA symptoms presence (n = 243), as well as patients with OSA suspicion (n = 75). A total of 318 patients (39% females) were subjected to ambulatory, one night polygraphic study (ApneaLink™). The following signals were recorded: airflow (pressure cannula), respiratory movements, and pulse oximetry. Additionally, anthropometrics, Epworth Sleepiness Scale (ESS), selected clinical symptoms, and drug-regimen were recorded. Results: Three hundred and eight (97%) patients completed the study (10 dropouts due to study failure). Patients were 57.7 ± 11.5 years old, had BMI = 30.0 ± 5.0 kg/m2, and average ESS = 5.7 ± 4.6. 65.3% of all patients were characterized by AHI ≥ 5 (62.2% vs. 74.7% in Random vs. Symptomatic group, respectively; P = 0.49), whereas 27.6% of patients were diagnosed with AHI ≥ 15 (23.6% in Random group and 40.0% in Symptomatic group). In logistic regression analysis, nocturia (> 2) increased the odds of AHI ≥ 30 diagnosis approximately 3.5 times in a fully adjusted model. Conclusions: Our results justify routine polygraphic screening of hypertensive patients requiring tertiary care. Abridged medical history may substantially increase the odds for positive screening.Background: Prevalence of obstructive sleep apnea (OSA) in patients with hypertension outnumbers the prevalence reported in the general population. Concurrently, majority of patients remain undiagnosed. Given the fact that untreated OSA contributes to ineffective hypotensive treatment, and higher rate of complications is ascribed to hypertension, early OSA diagnosis and its elimination constitutes one of the key clinical goals. Polysomnography comprises a golden standard in sleep apnea diagnosis, however it is a time-consuming and expensive procedure which requires hospitalization. Therefore, we assessed the utility of simplified polygraphic (PG) studies in the OSA screening of patients with hypertension requiring regular tertiary care. Material and methods: The study was conducted in the Outpatient Tertiary Care Clinic of the Medical University Hospital of Gdansk. We enrolled consecutive patients regardless of OSA symptoms presence (n = 243), as well as patients with OSA suspicion (n = 75). A total of 318 patients (39% females) were subjected to ambulatory, one night polygraphic study (ApneaLink™). The following signals were recorded: airflow (pressure cannula), respiratory movements, and pulse oximetry. Additionally, anthropometrics, Epworth Sleepiness Scale (ESS), selected clinical symptoms, and drug-regimen were recorded. Results: Three hundred and eight (97%) patients completed the study (10 dropouts due to study failure). Patients were 57.7 ± 11.5 years old, had BMI = 30.0 ± 5.0 kg/m2, and average ESS = 5.7 ± 4.6. 65.3% of all patients were characterized by AHI ≥ 5 (62.2% vs. 74.7% in Random vs. Symptomatic group, respectively; P = 0.49), whereas 27.6% of patients were diagnosed with AHI ≥ 15 (23.6% in Random group and 40.0% in Symptomatic group). In logistic regression analysis, nocturia (> 2) increased the odds of AHI ≥ 30 diagnosis approximately 3.5 times in a fully adjusted model. Conclusions: Our results justify routine polygraphic screening of hypertensive patients requiring tertiary care. Abridged medical history may substantially increase the odds for positive screening

Restoration of sinus rhythm does not improve peripheral blood flow in hemodynamically stable patients with atrial fibrillation

Background. Atrial fibrillation (AFib) is the most common atrial tachyarrhythmia with multiple negative hemodynamicconsequences. Although there have been many studies on the effects of AFib on cardiac function, very fewhave focused on changes in peripheral circulation during arrhythmia. Therefore, the aim of the present study was todetermine the effect of the reversal of AFib to sinus rhythm (SR) on peripheral blood flow. Material and methods. The forearm blood flow was determined by strain gauge plethysmography (EC 5R, Hokanson,Bellevue, USA) in hemodynamically stable 41 patients aged 63 ± 12 years with paroxysmal or persistent AFib.Venous capacity (VC), venous outflow (VO) and V0.5–2.0 index, arterial inflow (AI) and fast blood flow (FBF) weremeasured. 24 patients underwent successful cardioversion. The assessment of peripheral blood flow, BP and HR wasperformed during arrhythmia and then replicated within 7 day period after restoring of SR. Results. At baseline, plethysmographic parameters, heart rate, systolic and diastolic BP did not differ significantlyfor patients who underwent successful cardioversion vs. in those who failed to restore SR. Conversion of AFib to SRdid not change values of indices characterizing both venous and arterial vessels, values of systolic and diastolic bloodpressure, whereas heart rate was significantly reduced. Conclusions. Restoration of sinus rhythm does not improve peripheral blood flow in hemodynamically stable patientswith AFib in short term observation

Zastosowanie przesiewowych badań poligraficznych w diagnostyce bezdechu sennego u pacjentów z nadciśnieniem tętniczym wymagających specjalistycznej opieki ambulatoryjnej

Wprowadzenie: Pacjenci z nadciśnieniem tętniczym (NT) charakteryzują się znacznie częstszym współwystępowaniem obturacyjnego bezdechu sennego (OBS) w porównaniu do populacji ogólnej. Nieleczony bezdech zmniejsza efektywność terapii hipotensyjnej, a także w złożonym mechanizmie związany jest ze wzrostem występowania powikłań sercowo-naczyniowych charakterystycznych dla nadciśnienia tętniczego. W tym świetle, wczesna diagnostyka OBS i jego skuteczne leczenie stanowi jeden z podstawowych celów w postępowaniu z chorym z nadciśnieniem tętniczym, co jest szczególnie istotne z uwagi na niską rozpoznawalność OBS w tej grupie chorych. Złotym standardem w diagnostyce zaburzeń snu stanowi polisomnografia, która jednak jest procedurą czasochłonną, wymagająca istotnych nakładów środków finansowych i przeprowadzenia hospitalizacji. Z tego względu celem naszej pracy była ocena zastosowania uproszczonych badań poligraficznych (PG) jako metody badań przesiewowych u pacjentów z nadciśnieniem tętniczym wymagających specjalistycznej opieki ambulatoryjnej. Materiały i metody: Badanie zostało przeprowadzone w Regionalnym Centrum Nadciśnienia Tętniczego UCK, GUMed w Gdańsku. Do badania zostało włączonych 234 pacjentów bez względu na występowanie lub brak objawów OBS, a także 75 pacjentów z klinicznym podejrzeniem choroby. Łącznie 318 (39% kobiet) chorych zostało poddanych ambulatoryjnej ocenie poligraficznej przez okres jednej nocy. Rejestracja poligraficzna obejmowała następujące sygnały: przepływ powietrza (kaniula ciśnieniowa), ruchy oddechowe i pulsoksymetria. Dodatkowo zebrano dane antropometryczne, informacje dotyczące wybranych objawów klinicznych oraz przyjmowanych leków, a także oceniono stopień senności przy pomocy kwestionariusza Epworth Sleepiness Scale (ESS). Wyniki: Trzystu ośmiu (97%) pacjentów ukończyło badanie (10 pacjentów wykluczono ze względu na niedostateczną jakość rejestracji). Pacjenci mieli średnio 57,7 ± 11,5 roku, BMI = 30,0 ± 5,0 kg/m2 oraz średni wynik w skali ESS = 5,7 ± 4,6. W badanej grupie 65,3% charakteryzowało się AHI ≥ 5 (62,2% vs. 74,7%, odpowiednio w grupie losowej i objawowej). W analizie wieloczynnikowej wykazano, że nykturia powyżej 2 ×, 3,5-krotnie zwiększała ryzyko rozpoznania ciężkiej postaci OBS (AHI > 30). Wnioski: Nasze badanie potwierdza wysoką trafność screeningu poligraficznego u pacjentów z nadciśnieniem tętniczym w rozpoznawaniu OBS. Właściwa interpretacja podstawowych danych klinicznych pacjenta, istotnie zwiększa szansę na dodatni screening

The accuracy of SpaceLabs 90207 in blood pressure monitoring in patients with atrial fibrillation

Purpose: Irregular heart rhythm in the course of atrial fibrillation (AFib) results in lower blood pressure (BP) measurements reproducibility which is further limited by various BP-monitors used. Therefore the aim of our study was to estimate accuracy of oscillometric BP measurement (SpaceLabs 90207) with reference to mercury manometer-based readings. Material and methods: Study was performed in 47 hemodynamically stable patients aged 63 ± 12 yo with paroxysmal or persistent AFib, at baseline. Patients were reassessed within one week after effective cardioversion (SR; n = 29). BP was measured using Y-tube connection allowing for simultaneous measurements on the same arm with SpaceLabs 90207 and referral method. Mean values were tested with paired t-tests. Additionally, concordance correlation coefficient (ρc) and Bland-Altman plots were assessed. Results were confronted with AAMI, and ESH-IP criteria. Results: Both during arrhythmia and sinus rhythm diastolic BP differed significantly (Δ = 4.6 ± 6.0 mm Hg, p < .001 and 2.1 ± 4.0 mm Hg, p < .001; for AFib, and SR, respectively), which was not the case for systolic BP. The ρc during arrhythmia equaled 0.89, and 0.75 for systolic and diastolic BP, respectively, which further improved while SR (0.96 and 0.89, respectively). Results confronted against AAMI and ESH-IP showed that all criteria were met except for one (60% vs. required 65% of paired differences of less than 5 mm Hg) during AFib. Conclusions: The direct comparisons of BP readings allowed to conclude that diastolic blood pressure tended to be slightly overestimated when assessed with SpaceLabs 90207 in patients with both, AFib and SR, which was not a case for systolic BP. When the results were confronted with available validation protocols requirements, all referral criteria were met except for one. Taken together, our results suggest acceptable BP readings dispersion of SpaceLabs 90207 in BP monitoring of patients with both AFib and SR

Lumen narrowing and increased wall to lumen ratio of retinal microcirculation are valuable biomarkers of hypertension-mediated cardiac damage

Purpose: In the course of hypertension, left ventricular hypertrophy and diastolic dysfunction develop very often and may progress toward heart failure. The aim of the study was to analyze the relationship between abnormalities of retinal microcirculation and cardiac damage defined as left ventricular hypertrophy and/or diastolic dysfunction. Materials and methods: The study comprised 88 patients with essential hypertension. The group was divided into two subgroups: hypertensives without cardiac damage (n = 55) and with cardiac damage (n = 33). Control group comprised 32 normotensive subjects. Scanning laser Doppler flowmetry was used to evaluate retinal microcirculation. Echocardiography was used to assess cardiac damage. Results: Lumen diameter of retinal arterioles was significantly smaller in patients with cardiac damage vs. controls (77 vs. 84 µm, p = 0.02). Additionally, there was an evident trend with respect to lumen diameter (LD) across all three studied subgroups; i.e.: the smallest dimeters were present in cardiac damage patients, moderate size in hypertensives’ without cardiac damage, and the largest diameters in healthy controls (pfor trend < 0.01). Lumen diameter was inversely correlated with cardiac intraventricular septum diameter (R = –0.25, p = 0.02), left ventricular mass (R = –0.24, p = 0.02), and left atrial volume (R = –0.22, p = 0.04). Wall to lumen ratio was associated with intraventricular septum diameter (R = 0.21, p = 0.044) and left atrial volume (R = 0.21, p = 0.045). In multivariable regression analysis, lumen diameter was independently associated with intraventricular septum diameter (β = –0.05, p = 0.03), left ventricular mass (β = –1.15, p = 0.04), and left atrial volume (β = –0.42, p = 0.047); wall to lumen ratio was independently associated with intraventricular septum diameter (β = 3.67, p = 0.02) and left atrial volume (β = 30.0, p = 0.04). Conclusions: In conclusion, retinal arterioles lumen diameter and wall to lumen ratio were independent biomarkers of cardiac damage. Retinal examination performed by means of scanning laser Doppler flowmetry might be a valuable tool to improve cardiovascular risk stratification of hypertensive patients

Non-invasive hemodynamic monitoring as a guide to drug treatment of uncontrolled hypertensive patients: effects on home blood pressure in the BEAUTY study

Background: In the BEAUTY study we investigated whether utilizing non-invasive monitoring of hemodynamic parameters combined with a drug selection algorithm (integrated hemodynamic management-IHM) compared to conventional drug selection may improve home BP in patients with uncontrolled hypertension. Methods: Uncontrolled (office systolic blood pressure (SBP) > 140 mmHg and ambulatory daytime SBP >135 mmHg while taking ≥2 antihypertensive drugs) essential hypertensive patients were referred to 5 European Hypertension Excellence Centers and, if eligible, were randomized into IHM-guided vs conventional treatment adjustment. Home blood pressure (BP) was taken with 2 repeated readings at 1–2 min intervals in the morning and in the evening (before drug intake and eating) during the week preceding the visit at the outpatient clinic after 5 min rest using a validated semi-automatic oscillometric arm cuff device and with a correct cuff bladder placement. Home blood pressure was measured in a sub-group of patients (n = 84) not significantly different from the other patients. Results: Home SBP changed from 152.1+/−15.8 and 149.8+/−11.8 mmHg to 131.0 +/−11.1 and 139.6+/−12.8 mmHg in IHM group (n = 46) and Control group (n = 38), respectively, showing significantly greater reduction in IHM than in Control group (d= −10.9 mmHg, 95% CI −17.77, −4.02), p = 0.002. The reduction remained significant after multiple adjustments, particularly for baseline home SBP, recruiting center, age, sex and BMI (SBPIHM-Control= −9,63 mmHg, 95% CI −14.28, −5.11) mmHg, p < 0.0001). Conclusion: Drug selection algorithm based on non-invasive hemodynamic monitoring induced larger reduction in home BP compared to conventional drug selection in uncontrolled hypertensive patients referred to European Hypertension Excellence Centers. Although the main BEAUTY study was negative, these home BP measurements taken by patients themselves may suggest that the integrated hemodynamic monitoring is useful in patients with uncontrolled hypertension. This finding might depend on specific features of home BP measurements which could make it recommended BP measurement method for drug trials