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Canadian Journal of Cardiology

Obstructive Sleep Apnea as a Cardiovascular Risk Factor—Beyond CPAP

Published:February 18, 2021DOI:https://doi.org/10.1016/j.cjca.2021.01.027

      Abstract

      Patients with obstructive sleep apnea (OSA) experience repetitive partial or complete airway collapse during sleep resulting in nocturnal hypoxia-normoxia cycling, and are at increased cardiovascular risk. The number of apneas and hypopneas indexed per hour of sleep (apnea-hypopnea index) along with the associated intermittent hypoxia predict the increased cardiovascular risk; thus, their attenuation or prevention are objectives of OSA therapy. Continuous positive airway pressure (CPAP) is the gold standard treatment for OSA and, when effective, mitigates the apnea-hypopnea index and hypoxemia. As such, it is reasonable to expect CPAP would decrease cardiovascular risk. However, 3 recent randomized clinical trials of CPAP vs usual care did not show any significant effects of CPAP in attenuating incident cardiovascular events in patients with OSA. In this review, we discuss these studies in addition to potential complementary therapeutic options to CPAP (eg, neurostimulation) and conclude with suggested therapeutic targets for future interventional studies (eg, the autonomic nervous system). Although these areas of research are exciting, they have yet to be tested to any similar degree of rigour as CPAP.

      Résumé

      Les patients atteints d’apnée obstructive du sommeil (AOS) ont, durant leur sommeil, des épisodes répétés de collapsus partiel ou complet des voies aériennes qui créent des cycles nocturnes d’hypoxie-normoxie accroissant le risque de maladies cardiovasculaires (MCV). Le nombre d’épisodes d’apnée et d’hypopnée par heure (indice d’apnée-hypopnée) ainsi que l’hypoxie intermittente qui en résulte permettent de prédire l’augmentation du risque de MCV; c’est pourquoi l’atténuation ou la prévention de ces épisodes sont des objectifs du traitement de l’AOS. La ventilation en pression positive continue (VPPC) est le traitement de référence de l’AOS et, lorsqu’elle est mise en œuvre, diminue l’indice d’apnée-hypopnée et l’hypoxémie. Il serait donc raisonnable de s’attendre à ce que la VPPC diminue le risque de MCV. Cependant, trois récents essais cliniques avec répartition aléatoire comparant la VPPC au traitement classique n’ont montré aucun effet significatif de la VPPC pour ce qui est d’atténuer les nouveaux événements cardiovasculaires chez les patients atteints d’AOS. Dans cet article de synthèse, nous examinons ces études ainsi que des mesures thérapeutiques susceptibles de compléter la VPPC (p. ex., neurostimulation) et concluons en proposant des cibles thérapeutiques à évaluer dans les études d’intervention futures (p. ex., le système nerveux autonome). Bien que ces avenues de recherche soient intéressantes, leur évaluation exige la même rigueur que celle observée pour la VPPC.
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