Table 1.
Overview of Clinical or Epidemiologic Studies Characterizing Sleep-disordered Breathing and Cardiac Structural and Electrophysiologic Indices
| Study | Predictor (No.) | Outcome | Results |
|---|---|---|---|
| Observational | |||
| Autonomic nervous system alterations | |||
| Bonsignore et al82 | OSA (29) vs OSA on CPAP after CPAP withdrawal (10) vs no OSA (11) | Baroreflex sensitivity | Lower baroreflex sensitivity in OSA improved with CPAP treatment |
| Electrical remodeling | |||
| Gillis et al34 | OSA without underlying cardiac, pulmonary, or nervous system disease (12) | RR and QT intervals before, during, and after apneas | RR and QT interval prolonged during apneas and decreased in postapnea hyperventilation, QTc shortened during apnea and postapnea periods |
| Roche et al32 | OSA (30) vs no OSA (44) | QT interval related to heart rate | QT interval related to heart rate shortening at low heart rates correlated with OSA severity |
| Smith et al83 | PSG ECG records of OSA participants (20) | RR, QT, and PR interval with spontaneous and respiratory-related arousals | RR and QT interval shortening during arousals, RR interval worse with respiratory-related arousals; QT and PR interval independent of arousal type |
| Barta et al84 | Untreated OSA (25) | Cardiac arrhythmias, QT parameters | Increase in QT interval at night, no change in QT dispersion or arrhythmias |
| Dursunoglu et al85 | Moderate to severe OSA (29) vs no OSA (20) | QT dispersion | Increased QT dispersion in OSA with positive correlation with AHI |
| Voigt et al31 | OSA (101) vs no OSA (98) without structural heart disease | QT intervals, QT dispersion | Higher QT dispersion in OSA group |
| Kilicaslan et al30 | Moderate to severe OSA (23) vs no OSA (23) during PSG | Tp/Te interval, Tp/Te/QT ratio, Tp/Te/QTc ratio | All measures were increased in OSA group |
| Cagirci et al86 | No OSA (39) vs moderate OSA (42) vs severe OSA (45) | Atrial electromechanical coupling, intra-atrial and inter-atrial electromechanical delay, P-wave dispersion | Increased maximum P-wave duration and P-wave dispersion increased with OSA severity. Increased electromechanical delay for all indices correlating with OSA severity |
| Dimitri et al87 | Paroxysmal AF ablation: OSA (20) vs no OSA (20) | Atrial ERP, conduction, corrected sinus node recovery time, complex electrograms | Prolonged conduction times; increased number, duration, and more widespread complex electrograms; longer sinus node recovery time and P-wave duration; lower atrial voltage and slower conduction velocity in OSA |
| Yagmur et al79 | Moderate to severe OSA (64) vs no OSA (39) | Electromechanical delay, P-wave dispersion | Increased inter-atrial and intra-atrial electromechanical delay, and P-wave dispersion in OSA |
| Drager et al63 | Control (15) vs OSA (15) vs HTN (15) vs OSA + HTN (15) | Pulse wave velocity, left atrial diameter, ventricular septal thickness, percent LV hypertrophy, LV posterior wall thickness, LV mass index | Pulse wave velocity, left atrial diameter, ventricular septal mass, LV thickness, and hypertrophy increased in OSA, further increase in LV mass index and hypertrophy in OSA + HTN group |
| Cardiac structural changes | |||
| Kim et al88 | Mild to moderate OSA (24) vs severe OSA (20) vs no OSA (20) | Echocardiography indices of diastolic dysfunction | Decreased early diastolic velocity in severe OSA; AHI correlated with tissue Doppler imaging indexes of LV diastolic function but not conventional Doppler indices |
| Cioffi et al64 | Control (20) vs mild OSA (51) vs moderate/severe OSA (86) | LV mass, relative wall thickness, concentric LV geometry | Relative wall thickness and LV concentric geometry associated with OSA |
| Drager et al89 | Moderate to severe OSA (43) vs no OSA (30) | Pulse wave velocity, ejection fraction, left atrial diameter, LV mass index | Left atrial diameter, LV mass index, and pulse wave velocity increased in OSA |
| Arrhythmogenesis | |||
| Matiello et al90 | No OSA (132) vs mild to moderate OSA (17) vs severe OSA (25) after pulmonary vein ablation | AF or atrial flutter recurrence | Increased AF or atrial flutter recurrence with increasing OSA severity |
| Fein et al91 | OSA with CPAP (32) vs no CPAP (32) after pulmonary vein isolation | Atrial tachyarrhythmia, antiarrhythmic drugs, need for repeat ablation | Increase AF-free survival and decreased antiarrhythmic drug use or repeat ablation in CPAP group |
| Naruse et al92 | OSA no CPAP (32) vs OSA on CPAP (34) vs no OSA (37) after pulmonary vein isolation | AF recurrence | OSA, particularly without CPAP, increases risk of recurrent AF |
| Interventional | |||
| Autonomic sympathetic system alterations | |||
| Tkacova et al93 | Before/after CPAP in patients with heart failure and OSA | Baroreflex sensitivity for heart rate | Increased baroreceptor reflex sensitivity, lower heart rate, and lower BP on CPAP |
| Bonsignore et al94 | Before/after acute CPAP application in severe OSA (18) | Baroreflex sensitivity, BP | No change in mean BP or heart rate, small increase in mean baroreflex sensitivity, decreased cardiovascular variability with CPAP |
| Ruttanaumpawan et al95 | RCT, 1 mo CPAP (19) vs no therapy (14) in heart failure and OSA | Baroreflex sensitivity, echocardiographic indices | Increased baroreflex sensitivity, improved ejection fraction, lower daytime heart rate and BP with CPAP |
| Tamisier et al96 | Before/after CIH × 2 wk in healthy volunteers (12) | Sympathetic muscle nerve activity, BP, baroreflex control | Increases in daytime BP and sympathetic tone with decrease in baroreflex control after CIH |
| Tamisier et al97 | Hypocapnic hypoxia vs hypercapnic hypoxia × 20 min in healthy volunteers (12) | Muscle sympathetic nerve activity | Increased sympathetic activity with both groups but sustained after exposure in hypercapnic hypoxia |
| Usui et al98 | RCT, OSA (9) vs OSA + CPAP (8) in heart failure | Muscle sympathetic nerve activity, BP, heart rate | Decreased sympathetic nerve activity, BP, and heart rate with CPAP |
| Kohler et al99 | RCT, CPAP (20) vs sham CPAP (20) × 2 wk in previously treated OSA | BP, heart rate, urinary catecholamines | Increase in both systolic and diastolic morning BP, heart rate, and urinary catecholamines with sham CPAP |
| Phillips et al100 | Before/after CPAP withdrawal × 7 d from moderate to severe OSA (20) | Sympathetic activity, inflammatory cytokine levels | Increased urinary noradrenaline but no change in measured cytokines from CPAP withdrawal |
| Electrical remodeling | |||
| Roche et al33 | OSA (38) vs OSA + CPAP treatment (same group) vs matched no OSA (38) | QT and RT intervals, ventricular ectopy | QT length related to heart rate elevated in OSA with improvement with CPAP, no change in ventricular ectopy or QT or RT intervals with CPAP |
| Chrysostomakis et al101 | Before/after 2 mo of CPAP (26) vs no OSA (19) | Heart rate variability indices | Increased parasympathetic activity at night in those with OSA alleviated with CPAP |
| Dursunoglu et al102 | Before/after 6 mo adherent CPAP (18) vs nonadherent (11) | QT dispersion | Positive correlation of initial QT dispersion with AHI, which decreased after CPAP therapy; no change in nonadherent CPAP group |
| Rossi et al103 | RCT, patients with OSA continue on CPAP (20) vs subtherapeutic CPAP × 2 wk (21) | QT, TpTe (repolarization metrics), TpTe/QT (dispersion metric) | Increase in QT, TpTe intervals, and TpTe/QT ratio in subtherapeutic CPAP correlating with change in AHI from baseline treatment |
| Baranchuk et al104 | Before/after severe OSA on CPAP × 4-6 wk (19) vs no OSA/CPAP (10) | Signal-averaged P-wave duration | Increased signal-averaged P-wave duration in OSA ameliorated with CPAP indicating reversal of atrial remodeling |
| Camen et al16 | Randomized crossover study, healthy volunteers simulated obstructive apneas and hypopneas (41) | QTc and TpTec interval | Increased premature beats, increased QTc and TpTec interval |
| Maeno et al105 | Before/after 1 mo of CPAP in moderate to severe OSA (62) vs untreated moderate to severe OSA (18) | Signal-averaged P-wave duration | Significantly shorter signal-averaged P-wave duration with CPAP therapy correlating with compliance, no change in untreated OSA |
| Bayır et al106 | Before/after OSA with 6 mo of CPAP therapy (24) vs no OSA/CPAP (18) | Time 0 and 6-mo inter-atrial and intra-atrial electromechanical delay | Electromechanical delay greater in OSA group compared with control subjects with improvement after CPAP therapy |
| Cardiac structural remodeling | |||
| Dursunoglu et al107 | Before/after 6 mo of CPAP (67) | Interventricular septum and posterior wall thickness, myocardial performance index | Decreased thickness of both cardiac sites and improved myocardial performance index with CPAP |
| Dursunoglu et al108 | Before/after 6 mo of CPAP (18) | RV end-diastolic and end-systolic diameter, free wall diameter, and myocardial performance index | No change in end-diastolic or end-systolic diameters, decrease in free wall diameter, and improvement in RV myocardial performance index |
| Orban et al61 | Before/after healthy adults undergoing Müller maneuver (24) | Left atrial volume index, LV end-systolic dimension, ejection fraction, cardiac output | Decreased left atrial volume index and ejection fraction, increased LV end systolic dimension and cardiac output with maneuver |
| Oliveira et al109 | RCT, OSA with CPAP (15) vs sham CPAP (15) | Baseline, 12-wk, and 24-wk left atrial volume, LV diastolic performance | Improved left atrial emptying and LV diastolic function but not left atrial structural changes with CPAP |
| Koshino et al62 | Before/after healthy adults undergoing Müller maneuver (24) | Echocardiographic strain and strain rate measurements | LV and RV strain and strain rate decreased (worse ventricular mechanics) during maneuver |
| Colish et al110 | Before/after 1 year CPAP (47) | Echocardiographic remodeling indices | RV end-diastolic diameter, left and right atrial volume index, and pulmonary hypertension improvement with CPAP |
| Oliveira et al111 | RCT, OSA with CPAP (15) vs sham CPAP (15) | Baseline, 12-wk, and 24-wk left atrial volume, RV performance | Better RV performance but not structure with CPAP |
| Vural et al112 | Control (45) vs mild (22) vs moderate (27) vs severe (68) OSA; comparison vs severe OSA + CPAP for 24 wk (43) | Echocardiography indices of left atrial and LV structure and function | Worse left atrial function and LV filling pressure in severe OSA improved with CPAP |
| Arrhythmogenesis | |||
| Craig et al113 | RCT, CPAP (43) vs subtherapeutic CPAP (40) × 1 mo in moderate to severe OSA | Dysrhythmia frequency, heart rate | Decreased mean 24-h heart rate but no change in frequency of dysrhythmias with CPAP |
AF = atrial fibrillation; AHI = apnea-hypoapnea index; CIH = chronic intermittent hypoxia; ERP = effective refractory period; HTN = hypertension; LV = left ventricular; PSG = polysomnography; QTc = corrected QT interval; RCT = randomized controlled trial; RV = right ventricular; Tp/Te = interval between the ECG T-wave peak and end.