Pressman, Gregg S.

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Letter Regarding Article by Arias et al,“Obstructive Sleep Apnea Syndrome Affects LeftVentricular Diastolic Function: Effects of NasalContinuous Positive Airway Pressure in Men”To the Editor:I read with great interest the article by Arias et al1 regardingeffects of continuous positive airway pressure (CPAP) on dia-stolic function in patients with obstructive sleep apnea. Theirstudy was meticulously done, and I applaud their effort incarrying out this project. Although they state that their data showan improvement in diastolic function after 12 weeks of CPAP,there are other possible interpretations to be considered. Thegroup in whom changes in diastolic parameters were noted wasolder, with higher body mass index, blood pressure, and leftventricular mass. The vast majority had a pattern of impairedrelaxation. Although there were statistically significant decreasesin deceleration time and isovolumic relaxation time and asignificant increase in E:A ratio, no patient changed to a differentdiastolic pattern, and there were no measurable changes inventricular structure. The Doppler parameters that changed aresensitive to changes in diastolic function but also loadingconditions, in particular left atrial pressure. In some of thepatients, therefore, these changes might have been due toprogression of diastolic dysfunction in the direction of a pseudo-normal pattern.2Given the careful study design, I do think the authors’conclusion that diastolic function improved is quite possible. Ialso agree with them that tissue Doppler analysis would havebeen helpful. In light of reported improvement in systolicfunction after treatment of obstructive sleep apnea patients witha reduced ejection fraction,3 it would also be interesting to studythe effects of CPAP on Doppler (including tissue Doppler)parameters of systolic function.DisclosuresNone.Gregg S. Pressman, MDSt. Francis Medical CenterTrenton, NJ1. Arias MA, Garcia-Rio F, Alonso-Fernandez AA, Mediano O, Martinez I,Villamor J. Obstructive sleep apnea syndrome affects left ventriculardiastolic function: effects of nasal continuous positive airway pressure inmen. Circulation. 2005;112:375–383.2. Khouri SJ, Maly GT, Suh DD, Walsh TE. A practical approach to theechocardiographic evaluation of diastolic function. J Am Soc Echo-cardiogr. 2004;17:290–297.3. Kaneko Y, Floras JS, Usui K, Plante J, Tkacova R, Kubo T, Ando S,Bradley TD. Cardiovascular effects of continuous positive airwaypressure in patients with heart failure and obstructive sleep apnea. N EnglJ Med. 2003;348:1233–1241.ResponseWe thank Dr Pressman for his interest in our article on boththe presence of diastolic dysfunction in obstructive sleep apnea(OSA) patients and the effects of continuous positive airwaypressure (CPAP) on echocardiographic parameters of diastolicfunction.1 As we stated in the article, we share Dr Pressman’sview that tissue Doppler could have been helpful for assessingdiastolic function in our selected group of OSA patients withnormal systolic function. Certainly, the simplest approach todifferentiate between normal and pseudonormal left ventricularfilling patterns is the measurement of annular tissue velocity bytissue Doppler imaging. However, we sincerely believe ourapproach is valid to achieve the objectives of the study becausethe use of pulmonary venous flow by Doppler echocardiographyis a widely accepted tool in both differentiating between normaland pseudonormal patterns in the presence of sinus rhythm andestimating left ventricular filling pressures.2,3Although the mitral and pulmonary vein inflow pulsed-waveDoppler parameters are influenced by several factors such asheart rate, blood pressure, contractility, and loading conditions,the great majority of them were greatly controlled in our study.Our conclusion that diastolic dysfunction at baseline improvedafter CPAP treatment is based on the fact that significant changesobtained in the Doppler mitral flow parameters were not accom-panied by significant changes in the direction of a pseudonormalpattern such as changes in the pulmonary venous flow variables(decrease in S/D and A/AR ratios) or increased values for leftatrial diameter.3Nevertheless, further investigations are warranted to determinethe clinical benefits of long-term CPAP therapy in nonselectedOSA patients with diastolic dysfunction and the real prevalenceof isolated left ventricular diastolic dysfunction in OSA subjectsbased on large-scale epidemiological studies.DisclosuresNone.Miguel A. Arias, MD, PhDServicio de CardiologíaHospital Universitario La PazMadrid, SpainFrancisco García-Río, MD, PhDAlberto Alonso-Fernández, MD, PhDOlga Mediano, MDJosé Villamor, MD, PhDServicio de NeumologíaHospital Universitario La PazMadrid, SpainIsabel Martínez, MDLaboratorio de BioquímicaHospital Universitario La PazMadrid, Spain1. Arias MA, Garcia-Rio F, Alonso-Fernandez A, Mediano O, Martinez I,Villamor J. Obstructive sleep apnea syndrome affects left ventriculardiastolic function: effects of nasal continuous positive airway pressure inmen. Circulation. 2005;112:375–383.2. Tabata T, Thomas JD, Klein AL. Pulmonary venous flow by Dopplerechocardiography: revisited 12 years later. J Am Coll Cardiol. 2003;41:1243–1250.3. Appleton CP, Galloway JM, Gonzalez MS, Gaballa M, Basnight MA.Estimation of left ventricular filling pressures using two-dimensional andDoppler echocardiography in adult patients with cardiac disease: addi-tional value of analyzing left atrial size, left atrial ejection fraction and thedifference in duration of pulmonary venous and mitral flow velocity atatrial contraction. J Am Coll Cardiol. 1993;22:1972–1982.e11Correspondence by guest on December 26, 2016http://circ.ahajournals.org/Downloaded from Gregg S. PressmanMen''Ventricular Diastolic Function: Effects of Nasal Continuous Positive Airway Pressure in Letter Regarding Article by Arias et al, ''Obstructive Sleep Apnea Syndrome Affects LeftPrint ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 2006 American Heart Association, Inc. All rights reserved.is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231Circulation doi: 10.1161/CIRCULATIONAHA.105.5845992006;113:e11Circulation.  http://circ.ahajournals.org/content/113/1/e11World Wide Web at: The online version of this article, along with updated information and services, is located on the   http://circ.ahajournals.org//subscriptions/is online at: Circulation  Information about subscribing to Subscriptions:   http://www.lww.com/reprints Information about reprints can be found online at: Reprints:  document. Permissions and Rights Question and Answer this process is available in theclick Request Permissions in the middle column of the Web page under Services. Further information aboutOffice. 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Letter regarding article by Arias et al, obstructive sleep apnea syndrome affects left ventricular diastolic function: effects of nasal continuous positive airway pressure in men .

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