Sleep Medicine

SAN ANTONIO – Obstructive sleep apnea (OSA) in children is associated with an abnormal metabolic profile, but not with body mass index (BMI), according to new research.

Tara Haelle/MDedge News

“Screening for metabolic dysfunction in obese children with obstructive sleep apnea can help identify those at risk for cardiovascular complications,” Kanika Mathur, MD, of the Albert Einstein College of Medicine and the Children’s Hospital at Montefiore, both in New York, told attendees at the annual meeting of the American College of Chest Physicians. Dr. Mathur explained that no consensus currently exists regarding routine cardiac evaluation of children with OSA.

“The American Academy of Pediatrics does not mention any sort of cardiac evaluation in children with OSA while the most recent guidelines from the American Heart Association and the American Thoracic Society recommend echocardiographic evaluation in children with severe obstructive sleep apnea, specifically to evaluate for pulmonary hypertension and right ventricular dysfunction,” Dr. Mathur told attendees.

OSA’s association with obesity, diabetes, and hypertension is well established in adults. It is an independent risk factor for coronary artery disease, heart failure, stroke and atrial fibrillation, and research has suggested OSA treatment can reduce cardiovascular risk in adults, Dr. Mathur explained, but little data on children exist. She and her colleagues set out to understand the relationship of OSA in children with various measures of cardiovascular and metabolic health.

“Despite similar degrees of obesity and systemic blood pressure, pediatric patients with OSA had significantly higher diastolic blood pressure, heart rate, and abnormal metabolic profile, including elevated alanine transaminase, aspartate transaminase, triglycerides and hemoglobin A_1c,” they found.

Their study included patients aged 3-21 years with a BMI of at least the 95th percentile who had undergone sleep study and an echocardiogram at the Children’s Hospital at Montefiore between November 2016 and November 2017.

They excluded those with comorbidities related to cardiovascular morbidity: heart disease, neuromuscular disease, sickle cell disease, rheumatologic diseases, significant cranial facial abnormalities, tracheostomy, and any lung disease. However, 7% of the patients had trisomy 21.

Among the 81 children who met their criteria, 37 were male and 44 were female, with an average age of 14 years old and a mean BMI of 39.4 kg/m² (mean BMI z score of 2.22). Most of the patients (53.1%) had severe OSA (apnea-hypopnea index of at least 10), 21% had moderate OSA (AHI 5-9.9), 12.3% had mild OSA (AHI 2-4.9), and 13.6% did not have OSA. The median AHI of the children was 10.3.

Among all the children, “about half had elevated systolic blood pressure, which is already a risk factor for cardiovascular morbidity,” Mathur reported.

BMI, BMI z score, systolic blood pressure z score, oxygen saturation and cholesterol (overall and both HDL and LDL cholesterol levels) did not significantly differ between children who had OSA and those who did not, but diastolic blood pressure and heart rate did. Those with OSA had a diastolic blood pressure of 65 mm Hg, compared with 58 mm Hg without OSA (P = .008). Heart rate was 89 bpm in the children with OSA, compared with 78 bpm in those without (P = .004).

The children with OSA also showed higher mean levels of several other metabolic biomarkers:

• Alanine transaminase: 26 U/L with OSA vs. 18 U/L without (P = .01).
• Aspartate transaminase: 23 U/L with OSA vs. 18 U/L without (P = .03).
• Triglycerides: 138 mg/dL with OSA vs 84 mg/dL without (P = .004).
• Hemoglobin A_1c: 6.2% with OSA vs. 5.4% without (P = .002).

Children with and without OSA did not have any significant differences in left atrial indexed volume, left ventricular volume, left ventricular ejection fraction, or left ventricular mass (measured by M-mode or 5/6 area length formula). Though research has shown these measures to differ in adults with and without OSA, evidence on echocardiographic changes in children has been conflicting, Dr. Mathur noted.

The researchers also conducted subanalyses according to OSA severity, but BMI, BMI Z-score, systolic or diastolic blood pressure Z-score, heart rate and oxygen saturation did not differ between those with mild OSA vs those with moderate or severe OSA. No differences in echocardiographic measurements existed between these subgroups, either.

However, children with moderate to severe OSA did have higher alanine transaminase (27 U/L with moderate to severe vs. 17 U/L with mild OSA; P = .005) and higher triglycerides (148 vs 74; P = .001).

“Certainly we need further evaluation to see the efficacy of obstructive sleep apnea therapies on metabolic dysfunction and whether weight loss needs to be an adjunct therapy for these patients,” Dr. Mathur told attendees. She also noted the need to define the role of echocardiography in managing children with OSA.

The study had several limitations, including its retrospective cross-sectional nature at a single center and its small sample size.

Andrew D. Bowser/MDedge News

“Additionally, we have a wide variety of ages, which could represent different pathophysiology of the associated metabolic dysfunction in these patients,” Mathur said. “There is an inherent difficulty to performing echocardiograms in a very obese population as well.”

Both the moderators of the pediatrics section, Christopher Carroll, MD, FCCP, of Connecticut Children’s Medical Center in Hartford, and Shahid Sheikh, MD, FCCP, of Nationwide Children’s Hospital in Columbus, Ohio, were impressed with the research. Dr. Carroll called it a “very elegant” study, and Dr. Sheikh noted the need for these studies in pediatrics “so that we don’t have to rely on grown-up data,” which may or may not generalize to children.

SOURCE: CHEST 2018. https://journal.chestnet.org/article/S0012-3692(18)31935-4/fulltext

SAN ANTONIO – Obstructive sleep apnea (OSA) in children is associated with an abnormal metabolic profile, but not with body mass index (BMI), according to new research.

Tara Haelle/MDedge News

“Screening for metabolic dysfunction in obese children with obstructive sleep apnea can help identify those at risk for cardiovascular complications,” Kanika Mathur, MD, of the Albert Einstein College of Medicine and the Children’s Hospital at Montefiore, both in New York, told attendees at the annual meeting of the American College of Chest Physicians. Dr. Mathur explained that no consensus currently exists regarding routine cardiac evaluation of children with OSA.

“The American Academy of Pediatrics does not mention any sort of cardiac evaluation in children with OSA while the most recent guidelines from the American Heart Association and the American Thoracic Society recommend echocardiographic evaluation in children with severe obstructive sleep apnea, specifically to evaluate for pulmonary hypertension and right ventricular dysfunction,” Dr. Mathur told attendees.

OSA’s association with obesity, diabetes, and hypertension is well established in adults. It is an independent risk factor for coronary artery disease, heart failure, stroke and atrial fibrillation, and research has suggested OSA treatment can reduce cardiovascular risk in adults, Dr. Mathur explained, but little data on children exist. She and her colleagues set out to understand the relationship of OSA in children with various measures of cardiovascular and metabolic health.

“Despite similar degrees of obesity and systemic blood pressure, pediatric patients with OSA had significantly higher diastolic blood pressure, heart rate, and abnormal metabolic profile, including elevated alanine transaminase, aspartate transaminase, triglycerides and hemoglobin A_1c,” they found.

Their study included patients aged 3-21 years with a BMI of at least the 95th percentile who had undergone sleep study and an echocardiogram at the Children’s Hospital at Montefiore between November 2016 and November 2017.

They excluded those with comorbidities related to cardiovascular morbidity: heart disease, neuromuscular disease, sickle cell disease, rheumatologic diseases, significant cranial facial abnormalities, tracheostomy, and any lung disease. However, 7% of the patients had trisomy 21.

Among the 81 children who met their criteria, 37 were male and 44 were female, with an average age of 14 years old and a mean BMI of 39.4 kg/m² (mean BMI z score of 2.22). Most of the patients (53.1%) had severe OSA (apnea-hypopnea index of at least 10), 21% had moderate OSA (AHI 5-9.9), 12.3% had mild OSA (AHI 2-4.9), and 13.6% did not have OSA. The median AHI of the children was 10.3.

Among all the children, “about half had elevated systolic blood pressure, which is already a risk factor for cardiovascular morbidity,” Mathur reported.

BMI, BMI z score, systolic blood pressure z score, oxygen saturation and cholesterol (overall and both HDL and LDL cholesterol levels) did not significantly differ between children who had OSA and those who did not, but diastolic blood pressure and heart rate did. Those with OSA had a diastolic blood pressure of 65 mm Hg, compared with 58 mm Hg without OSA (P = .008). Heart rate was 89 bpm in the children with OSA, compared with 78 bpm in those without (P = .004).

The children with OSA also showed higher mean levels of several other metabolic biomarkers:

• Alanine transaminase: 26 U/L with OSA vs. 18 U/L without (P = .01).
• Aspartate transaminase: 23 U/L with OSA vs. 18 U/L without (P = .03).
• Triglycerides: 138 mg/dL with OSA vs 84 mg/dL without (P = .004).
• Hemoglobin A_1c: 6.2% with OSA vs. 5.4% without (P = .002).

Children with and without OSA did not have any significant differences in left atrial indexed volume, left ventricular volume, left ventricular ejection fraction, or left ventricular mass (measured by M-mode or 5/6 area length formula). Though research has shown these measures to differ in adults with and without OSA, evidence on echocardiographic changes in children has been conflicting, Dr. Mathur noted.

The researchers also conducted subanalyses according to OSA severity, but BMI, BMI Z-score, systolic or diastolic blood pressure Z-score, heart rate and oxygen saturation did not differ between those with mild OSA vs those with moderate or severe OSA. No differences in echocardiographic measurements existed between these subgroups, either.

However, children with moderate to severe OSA did have higher alanine transaminase (27 U/L with moderate to severe vs. 17 U/L with mild OSA; P = .005) and higher triglycerides (148 vs 74; P = .001).

“Certainly we need further evaluation to see the efficacy of obstructive sleep apnea therapies on metabolic dysfunction and whether weight loss needs to be an adjunct therapy for these patients,” Dr. Mathur told attendees. She also noted the need to define the role of echocardiography in managing children with OSA.

The study had several limitations, including its retrospective cross-sectional nature at a single center and its small sample size.

Andrew D. Bowser/MDedge News

“Additionally, we have a wide variety of ages, which could represent different pathophysiology of the associated metabolic dysfunction in these patients,” Mathur said. “There is an inherent difficulty to performing echocardiograms in a very obese population as well.”

Both the moderators of the pediatrics section, Christopher Carroll, MD, FCCP, of Connecticut Children’s Medical Center in Hartford, and Shahid Sheikh, MD, FCCP, of Nationwide Children’s Hospital in Columbus, Ohio, were impressed with the research. Dr. Carroll called it a “very elegant” study, and Dr. Sheikh noted the need for these studies in pediatrics “so that we don’t have to rely on grown-up data,” which may or may not generalize to children.

SOURCE: CHEST 2018. https://journal.chestnet.org/article/S0012-3692(18)31935-4/fulltext

SAN ANTONIO – Obstructive sleep apnea (OSA) in children is associated with an abnormal metabolic profile, but not with body mass index (BMI), according to new research.

Tara Haelle/MDedge News

“Screening for metabolic dysfunction in obese children with obstructive sleep apnea can help identify those at risk for cardiovascular complications,” Kanika Mathur, MD, of the Albert Einstein College of Medicine and the Children’s Hospital at Montefiore, both in New York, told attendees at the annual meeting of the American College of Chest Physicians. Dr. Mathur explained that no consensus currently exists regarding routine cardiac evaluation of children with OSA.

“The American Academy of Pediatrics does not mention any sort of cardiac evaluation in children with OSA while the most recent guidelines from the American Heart Association and the American Thoracic Society recommend echocardiographic evaluation in children with severe obstructive sleep apnea, specifically to evaluate for pulmonary hypertension and right ventricular dysfunction,” Dr. Mathur told attendees.

OSA’s association with obesity, diabetes, and hypertension is well established in adults. It is an independent risk factor for coronary artery disease, heart failure, stroke and atrial fibrillation, and research has suggested OSA treatment can reduce cardiovascular risk in adults, Dr. Mathur explained, but little data on children exist. She and her colleagues set out to understand the relationship of OSA in children with various measures of cardiovascular and metabolic health.

“Despite similar degrees of obesity and systemic blood pressure, pediatric patients with OSA had significantly higher diastolic blood pressure, heart rate, and abnormal metabolic profile, including elevated alanine transaminase, aspartate transaminase, triglycerides and hemoglobin A_1c,” they found.

Their study included patients aged 3-21 years with a BMI of at least the 95th percentile who had undergone sleep study and an echocardiogram at the Children’s Hospital at Montefiore between November 2016 and November 2017.

They excluded those with comorbidities related to cardiovascular morbidity: heart disease, neuromuscular disease, sickle cell disease, rheumatologic diseases, significant cranial facial abnormalities, tracheostomy, and any lung disease. However, 7% of the patients had trisomy 21.

Among the 81 children who met their criteria, 37 were male and 44 were female, with an average age of 14 years old and a mean BMI of 39.4 kg/m² (mean BMI z score of 2.22). Most of the patients (53.1%) had severe OSA (apnea-hypopnea index of at least 10), 21% had moderate OSA (AHI 5-9.9), 12.3% had mild OSA (AHI 2-4.9), and 13.6% did not have OSA. The median AHI of the children was 10.3.

Among all the children, “about half had elevated systolic blood pressure, which is already a risk factor for cardiovascular morbidity,” Mathur reported.

BMI, BMI z score, systolic blood pressure z score, oxygen saturation and cholesterol (overall and both HDL and LDL cholesterol levels) did not significantly differ between children who had OSA and those who did not, but diastolic blood pressure and heart rate did. Those with OSA had a diastolic blood pressure of 65 mm Hg, compared with 58 mm Hg without OSA (P = .008). Heart rate was 89 bpm in the children with OSA, compared with 78 bpm in those without (P = .004).

The children with OSA also showed higher mean levels of several other metabolic biomarkers:

• Alanine transaminase: 26 U/L with OSA vs. 18 U/L without (P = .01).
• Aspartate transaminase: 23 U/L with OSA vs. 18 U/L without (P = .03).
• Triglycerides: 138 mg/dL with OSA vs 84 mg/dL without (P = .004).
• Hemoglobin A_1c: 6.2% with OSA vs. 5.4% without (P = .002).

Children with and without OSA did not have any significant differences in left atrial indexed volume, left ventricular volume, left ventricular ejection fraction, or left ventricular mass (measured by M-mode or 5/6 area length formula). Though research has shown these measures to differ in adults with and without OSA, evidence on echocardiographic changes in children has been conflicting, Dr. Mathur noted.

The researchers also conducted subanalyses according to OSA severity, but BMI, BMI Z-score, systolic or diastolic blood pressure Z-score, heart rate and oxygen saturation did not differ between those with mild OSA vs those with moderate or severe OSA. No differences in echocardiographic measurements existed between these subgroups, either.

However, children with moderate to severe OSA did have higher alanine transaminase (27 U/L with moderate to severe vs. 17 U/L with mild OSA; P = .005) and higher triglycerides (148 vs 74; P = .001).

“Certainly we need further evaluation to see the efficacy of obstructive sleep apnea therapies on metabolic dysfunction and whether weight loss needs to be an adjunct therapy for these patients,” Dr. Mathur told attendees. She also noted the need to define the role of echocardiography in managing children with OSA.

The study had several limitations, including its retrospective cross-sectional nature at a single center and its small sample size.

Andrew D. Bowser/MDedge News

“Additionally, we have a wide variety of ages, which could represent different pathophysiology of the associated metabolic dysfunction in these patients,” Mathur said. “There is an inherent difficulty to performing echocardiograms in a very obese population as well.”

Both the moderators of the pediatrics section, Christopher Carroll, MD, FCCP, of Connecticut Children’s Medical Center in Hartford, and Shahid Sheikh, MD, FCCP, of Nationwide Children’s Hospital in Columbus, Ohio, were impressed with the research. Dr. Carroll called it a “very elegant” study, and Dr. Sheikh noted the need for these studies in pediatrics “so that we don’t have to rely on grown-up data,” which may or may not generalize to children.

SOURCE: CHEST 2018. https://journal.chestnet.org/article/S0012-3692(18)31935-4/fulltext

ATLANTA – Chronic gastroesophageal reflux disease (GERD) is associated with various sleep disorders that might complicate the response to GERD treatment, results from an ongoing longitudinal analysis demonstrated.

“We have little longitudinal information on GERD in the general population; the last published article on GERD incidence was 20 years ago,” lead study author Maurice M. Ohayon, MD, DSc, PhD, said in an interview in advance of the annual meeting of the American Neurological Association. “As a sleep specialist, I am always interested to see how a specific medical condition may affect the sleep quality of the individuals with that condition. How we live our day has an impact on our night; it works together.”

In an effort to examine the long-term effects of GERD on sleep disturbances, Dr. Ohayon, director of the Stanford (Calif.) Sleep Epidemiology Research Center, and his colleagues used U.S. Census data to identify a random sample of adults in Arizona, California, Colorado, Idaho, New York, Oregon, Pennsylvania, and Texas. The researchers conducted two waves of phone interviews with the subjects 3 years apart, beginning in 2004. They limited their analysis to 10,930 subjects with a mean age of 43 years who participated in both interviews.

Between wave 1 and wave 2 of phone interviews, the proportion of adults who reported having GERD rose from 10.6% to 12.4% and the prevalence of new GERD cases was 8.5% per year, while the incidence was 3.2% per year. Chronic GERD, defined as that present during both interview periods, was observed in 3.9% of the sample.

The researchers found that 77.3% of GERD subjects were taking a treatment to alleviate their symptoms, mostly proton-pump inhibitors. Those with chronic GERD were more likely to report being dissatisfied with their sleep during wave 2 of the study, compared with wave 1 (24.2% vs. 13.5%; P less than .001). In addition, compared with their non-GERD counterparts, those with chronic GERD were more likely to wake up at night (33.9% vs. 28.3%; P less than .001) and to have nonrestorative sleep (15.6% vs. 10.5%; P less than .001).

“Discomfort related to GERD may happen while you are sleeping,” said Dr. Ohayon, who is also a professor of psychiatry and behavioral sciences at Stanford University. “It may wake you up and, if not, it may make you feel unrested when you wake up. We observed both of these symptoms in our GERD participants. Insomnia disorders were also rampant in the chronic GERD group (24.5%, compared with 14.4% in non-GERD participants). An insomnia disorder is more than just having difficulty falling asleep or waking up at night, it means that your daytime functioning is affected by the poor quality of your night.”

Dr. Ohayon said other findings from the study were “rather alarming.” For example, individuals with GERD, especially those with the chronic form, weighed much more than those with no GERD did. “Over a 3-year period, the chronic GERD individuals gained one point in the body mass index, which for a 6-foot tall man translates into a weight gain of 30 pounds,” he said. “Of course, with that follows high blood pressure, high cholesterol, diabetes, chronic pain, and heart disease.”

He concluded that GERD has its main manifestations when affected individuals are sleeping on their backs. “The impact of GERD on the quality of sleep is major,” he said. “Sleepiness and fatigue during the day are the consequences impacting work, family, and quality of life.”

Dr. Ohayon acknowledged certain limitations of the study, including the fact that GERD was based on self-report. The study was supported by an unrestricted grant from Takeda.

dbrunk@mdedge.com

Source: Oyahon et al. ANA 2018, Abstract 625.

ATLANTA – Chronic gastroesophageal reflux disease (GERD) is associated with various sleep disorders that might complicate the response to GERD treatment, results from an ongoing longitudinal analysis demonstrated.

“We have little longitudinal information on GERD in the general population; the last published article on GERD incidence was 20 years ago,” lead study author Maurice M. Ohayon, MD, DSc, PhD, said in an interview in advance of the annual meeting of the American Neurological Association. “As a sleep specialist, I am always interested to see how a specific medical condition may affect the sleep quality of the individuals with that condition. How we live our day has an impact on our night; it works together.”

In an effort to examine the long-term effects of GERD on sleep disturbances, Dr. Ohayon, director of the Stanford (Calif.) Sleep Epidemiology Research Center, and his colleagues used U.S. Census data to identify a random sample of adults in Arizona, California, Colorado, Idaho, New York, Oregon, Pennsylvania, and Texas. The researchers conducted two waves of phone interviews with the subjects 3 years apart, beginning in 2004. They limited their analysis to 10,930 subjects with a mean age of 43 years who participated in both interviews.

Between wave 1 and wave 2 of phone interviews, the proportion of adults who reported having GERD rose from 10.6% to 12.4% and the prevalence of new GERD cases was 8.5% per year, while the incidence was 3.2% per year. Chronic GERD, defined as that present during both interview periods, was observed in 3.9% of the sample.

The researchers found that 77.3% of GERD subjects were taking a treatment to alleviate their symptoms, mostly proton-pump inhibitors. Those with chronic GERD were more likely to report being dissatisfied with their sleep during wave 2 of the study, compared with wave 1 (24.2% vs. 13.5%; P less than .001). In addition, compared with their non-GERD counterparts, those with chronic GERD were more likely to wake up at night (33.9% vs. 28.3%; P less than .001) and to have nonrestorative sleep (15.6% vs. 10.5%; P less than .001).

“Discomfort related to GERD may happen while you are sleeping,” said Dr. Ohayon, who is also a professor of psychiatry and behavioral sciences at Stanford University. “It may wake you up and, if not, it may make you feel unrested when you wake up. We observed both of these symptoms in our GERD participants. Insomnia disorders were also rampant in the chronic GERD group (24.5%, compared with 14.4% in non-GERD participants). An insomnia disorder is more than just having difficulty falling asleep or waking up at night, it means that your daytime functioning is affected by the poor quality of your night.”

Dr. Ohayon said other findings from the study were “rather alarming.” For example, individuals with GERD, especially those with the chronic form, weighed much more than those with no GERD did. “Over a 3-year period, the chronic GERD individuals gained one point in the body mass index, which for a 6-foot tall man translates into a weight gain of 30 pounds,” he said. “Of course, with that follows high blood pressure, high cholesterol, diabetes, chronic pain, and heart disease.”

He concluded that GERD has its main manifestations when affected individuals are sleeping on their backs. “The impact of GERD on the quality of sleep is major,” he said. “Sleepiness and fatigue during the day are the consequences impacting work, family, and quality of life.”

Dr. Ohayon acknowledged certain limitations of the study, including the fact that GERD was based on self-report. The study was supported by an unrestricted grant from Takeda.

dbrunk@mdedge.com

Source: Oyahon et al. ANA 2018, Abstract 625.

ATLANTA – Chronic gastroesophageal reflux disease (GERD) is associated with various sleep disorders that might complicate the response to GERD treatment, results from an ongoing longitudinal analysis demonstrated.

“We have little longitudinal information on GERD in the general population; the last published article on GERD incidence was 20 years ago,” lead study author Maurice M. Ohayon, MD, DSc, PhD, said in an interview in advance of the annual meeting of the American Neurological Association. “As a sleep specialist, I am always interested to see how a specific medical condition may affect the sleep quality of the individuals with that condition. How we live our day has an impact on our night; it works together.”

In an effort to examine the long-term effects of GERD on sleep disturbances, Dr. Ohayon, director of the Stanford (Calif.) Sleep Epidemiology Research Center, and his colleagues used U.S. Census data to identify a random sample of adults in Arizona, California, Colorado, Idaho, New York, Oregon, Pennsylvania, and Texas. The researchers conducted two waves of phone interviews with the subjects 3 years apart, beginning in 2004. They limited their analysis to 10,930 subjects with a mean age of 43 years who participated in both interviews.

Between wave 1 and wave 2 of phone interviews, the proportion of adults who reported having GERD rose from 10.6% to 12.4% and the prevalence of new GERD cases was 8.5% per year, while the incidence was 3.2% per year. Chronic GERD, defined as that present during both interview periods, was observed in 3.9% of the sample.

The researchers found that 77.3% of GERD subjects were taking a treatment to alleviate their symptoms, mostly proton-pump inhibitors. Those with chronic GERD were more likely to report being dissatisfied with their sleep during wave 2 of the study, compared with wave 1 (24.2% vs. 13.5%; P less than .001). In addition, compared with their non-GERD counterparts, those with chronic GERD were more likely to wake up at night (33.9% vs. 28.3%; P less than .001) and to have nonrestorative sleep (15.6% vs. 10.5%; P less than .001).

“Discomfort related to GERD may happen while you are sleeping,” said Dr. Ohayon, who is also a professor of psychiatry and behavioral sciences at Stanford University. “It may wake you up and, if not, it may make you feel unrested when you wake up. We observed both of these symptoms in our GERD participants. Insomnia disorders were also rampant in the chronic GERD group (24.5%, compared with 14.4% in non-GERD participants). An insomnia disorder is more than just having difficulty falling asleep or waking up at night, it means that your daytime functioning is affected by the poor quality of your night.”

Dr. Ohayon said other findings from the study were “rather alarming.” For example, individuals with GERD, especially those with the chronic form, weighed much more than those with no GERD did. “Over a 3-year period, the chronic GERD individuals gained one point in the body mass index, which for a 6-foot tall man translates into a weight gain of 30 pounds,” he said. “Of course, with that follows high blood pressure, high cholesterol, diabetes, chronic pain, and heart disease.”

He concluded that GERD has its main manifestations when affected individuals are sleeping on their backs. “The impact of GERD on the quality of sleep is major,” he said. “Sleepiness and fatigue during the day are the consequences impacting work, family, and quality of life.”

Dr. Ohayon acknowledged certain limitations of the study, including the fact that GERD was based on self-report. The study was supported by an unrestricted grant from Takeda.

dbrunk@mdedge.com

Source: Oyahon et al. ANA 2018, Abstract 625.

SAN ANTONIO – The ADVENT-HF trial, designed to test whether adaptive servo ventilation (ASV) improves cardiovascular outcomes in heart failure patients with sleep apnea, so far has better compliance than previous trials, with no safety concerns to date, according to investigator T. Douglas Bradley, MD.

On average, patients with obstructive sleep apnea were using the device 4.6 hours per night at 1 month and 4.1 hours at 12 months, while patients with central sleep apnea were using the device 5.2 hours per night both at 1 month and 12 months, Dr. Bradley said.

“This represents much better compliance than the other trials that have looked into this area, so we are quite happy about that,” Dr. Bradley said at the annual meeting of the American College of Chest Physicians.

The study has been reviewed five times by the data safety monitoring board since the announcement of SERVE-HF trial results, with no safety concerns in either obstructive sleep apnea or central sleep apnea patients, Dr. Bradley noted in a podium presentation.

The compliance results have been submitted for publication, though efficacy results of the study will have to wait. The estimated study completion date is June 2020, according to the latest study information on ClinicalTrials.gov.

More than 600 patients have been enrolled in ADVENT-HF to date, and the investigators hope to enroll more than 800: “We should be there by the end of next year,” Dr. Bradley said.

He provided disclosures related to Philips Respironics (funding and devices) and the Canadian Institutes of Health Research.

SAN ANTONIO – The ADVENT-HF trial, designed to test whether adaptive servo ventilation (ASV) improves cardiovascular outcomes in heart failure patients with sleep apnea, so far has better compliance than previous trials, with no safety concerns to date, according to investigator T. Douglas Bradley, MD.

On average, patients with obstructive sleep apnea were using the device 4.6 hours per night at 1 month and 4.1 hours at 12 months, while patients with central sleep apnea were using the device 5.2 hours per night both at 1 month and 12 months, Dr. Bradley said.

“This represents much better compliance than the other trials that have looked into this area, so we are quite happy about that,” Dr. Bradley said at the annual meeting of the American College of Chest Physicians.

The study has been reviewed five times by the data safety monitoring board since the announcement of SERVE-HF trial results, with no safety concerns in either obstructive sleep apnea or central sleep apnea patients, Dr. Bradley noted in a podium presentation.

The compliance results have been submitted for publication, though efficacy results of the study will have to wait. The estimated study completion date is June 2020, according to the latest study information on ClinicalTrials.gov.

More than 600 patients have been enrolled in ADVENT-HF to date, and the investigators hope to enroll more than 800: “We should be there by the end of next year,” Dr. Bradley said.

He provided disclosures related to Philips Respironics (funding and devices) and the Canadian Institutes of Health Research.

SAN ANTONIO – The ADVENT-HF trial, designed to test whether adaptive servo ventilation (ASV) improves cardiovascular outcomes in heart failure patients with sleep apnea, so far has better compliance than previous trials, with no safety concerns to date, according to investigator T. Douglas Bradley, MD.

On average, patients with obstructive sleep apnea were using the device 4.6 hours per night at 1 month and 4.1 hours at 12 months, while patients with central sleep apnea were using the device 5.2 hours per night both at 1 month and 12 months, Dr. Bradley said.

“This represents much better compliance than the other trials that have looked into this area, so we are quite happy about that,” Dr. Bradley said at the annual meeting of the American College of Chest Physicians.

The study has been reviewed five times by the data safety monitoring board since the announcement of SERVE-HF trial results, with no safety concerns in either obstructive sleep apnea or central sleep apnea patients, Dr. Bradley noted in a podium presentation.

The compliance results have been submitted for publication, though efficacy results of the study will have to wait. The estimated study completion date is June 2020, according to the latest study information on ClinicalTrials.gov.

More than 600 patients have been enrolled in ADVENT-HF to date, and the investigators hope to enroll more than 800: “We should be there by the end of next year,” Dr. Bradley said.

He provided disclosures related to Philips Respironics (funding and devices) and the Canadian Institutes of Health Research.

Sexual harassment and assault may have significant health impacts on women in midlife, including greater risk of hypertension, poor sleep, depression, and anxiety, research suggests.

thodonal/Thinkstock

In the Oct. 3 online edition of JAMA Internal Medicine, a study of 304 women aged 40-60 years showed that 19% reported a history of workplace sexual harassment, 22% reported a history of sexual assault, and 10% reported both. The report was presented simultaneously at the North American Menopause Society annual meeting in San Diego.

The researchers found that those with a history of sexual assault had an almost threefold higher odds of clinically elevated depressive symptoms (OR, 2.86, P = .003), and more than twofold greater odds of anxiety and poor sleep (OR, 2.26, P = .006 and OR, 2.15, P = .007 respectively).

Women who reported experiencing sexual harassment in the workplace – and who were not taking antihypertensive medication – were more than twice as likely to have stage 1 or 2 hypertension, compared with women who had not experienced sexual harassment (OR, 2.36, P = .03). They also had 89% higher odds of poor sleep consistent with clinical insomnia (P = .03).

These associations all persisted even after adjustment for demographic and biomedical factors such as age, ethnicity, body mass index, snoring, and the use of antihypertensive, antidepressant, and anti-anxiety medications.

“Given the high prevalence of sexual harassment and assault, addressing these prevalent and potent social exposures may be critical to promoting health and preventing disease in women,” wrote Rebecca C. Thurston, PhD, of the department of psychiatry at the University of Pittsburgh, and her coauthors.

The study was supported by the National Institutes of Health, National Heart Lung and Blood Institute, and the University of Pittsburgh Clinical and Translational Science Institute. Dr. Thurston declared consultancies for MAS Innovations, Procter & Gamble, and Pfizer, but no other conflicts of interest were declared.

SOURCE: Thurston R et al. JAMA Intern Med. 2018, Oct 3. doi: 10.1001/jamainternmed.2018.4886.

Sexual harassment and assault may have significant health impacts on women in midlife, including greater risk of hypertension, poor sleep, depression, and anxiety, research suggests.

thodonal/Thinkstock

In the Oct. 3 online edition of JAMA Internal Medicine, a study of 304 women aged 40-60 years showed that 19% reported a history of workplace sexual harassment, 22% reported a history of sexual assault, and 10% reported both. The report was presented simultaneously at the North American Menopause Society annual meeting in San Diego.

The researchers found that those with a history of sexual assault had an almost threefold higher odds of clinically elevated depressive symptoms (OR, 2.86, P = .003), and more than twofold greater odds of anxiety and poor sleep (OR, 2.26, P = .006 and OR, 2.15, P = .007 respectively).

Women who reported experiencing sexual harassment in the workplace – and who were not taking antihypertensive medication – were more than twice as likely to have stage 1 or 2 hypertension, compared with women who had not experienced sexual harassment (OR, 2.36, P = .03). They also had 89% higher odds of poor sleep consistent with clinical insomnia (P = .03).

These associations all persisted even after adjustment for demographic and biomedical factors such as age, ethnicity, body mass index, snoring, and the use of antihypertensive, antidepressant, and anti-anxiety medications.

“Given the high prevalence of sexual harassment and assault, addressing these prevalent and potent social exposures may be critical to promoting health and preventing disease in women,” wrote Rebecca C. Thurston, PhD, of the department of psychiatry at the University of Pittsburgh, and her coauthors.

The study was supported by the National Institutes of Health, National Heart Lung and Blood Institute, and the University of Pittsburgh Clinical and Translational Science Institute. Dr. Thurston declared consultancies for MAS Innovations, Procter & Gamble, and Pfizer, but no other conflicts of interest were declared.

SOURCE: Thurston R et al. JAMA Intern Med. 2018, Oct 3. doi: 10.1001/jamainternmed.2018.4886.

Sexual harassment and assault may have significant health impacts on women in midlife, including greater risk of hypertension, poor sleep, depression, and anxiety, research suggests.

thodonal/Thinkstock

In the Oct. 3 online edition of JAMA Internal Medicine, a study of 304 women aged 40-60 years showed that 19% reported a history of workplace sexual harassment, 22% reported a history of sexual assault, and 10% reported both. The report was presented simultaneously at the North American Menopause Society annual meeting in San Diego.

The researchers found that those with a history of sexual assault had an almost threefold higher odds of clinically elevated depressive symptoms (OR, 2.86, P = .003), and more than twofold greater odds of anxiety and poor sleep (OR, 2.26, P = .006 and OR, 2.15, P = .007 respectively).

Women who reported experiencing sexual harassment in the workplace – and who were not taking antihypertensive medication – were more than twice as likely to have stage 1 or 2 hypertension, compared with women who had not experienced sexual harassment (OR, 2.36, P = .03). They also had 89% higher odds of poor sleep consistent with clinical insomnia (P = .03).

These associations all persisted even after adjustment for demographic and biomedical factors such as age, ethnicity, body mass index, snoring, and the use of antihypertensive, antidepressant, and anti-anxiety medications.

“Given the high prevalence of sexual harassment and assault, addressing these prevalent and potent social exposures may be critical to promoting health and preventing disease in women,” wrote Rebecca C. Thurston, PhD, of the department of psychiatry at the University of Pittsburgh, and her coauthors.

The study was supported by the National Institutes of Health, National Heart Lung and Blood Institute, and the University of Pittsburgh Clinical and Translational Science Institute. Dr. Thurston declared consultancies for MAS Innovations, Procter & Gamble, and Pfizer, but no other conflicts of interest were declared.

SOURCE: Thurston R et al. JAMA Intern Med. 2018, Oct 3. doi: 10.1001/jamainternmed.2018.4886.

Patients with overweight and obesity are at increased risk of multiple morbidities, including cardiovascular disease, stroke, type 2 diabetes (T2D), osteoarthritis, obstructive sleep apnea (OSA), and all-cause mortality.¹ Even modest weight loss—5% to 10%—can lead to a clinically relevant reduction in this risk of disease.^2,3 The American Academy of Family Physicians recognizes obesity as a disease, and recommends screening of all adults for obesity and referral for those with body mass index (BMI)* ≥30 to intensive, multicomponent behavioral interventions.^4,5

For some patients, diet, exercise, and behavioral modifications are sufficient; for the great majority, however, weight loss achieved by lifestyle modification is counteracted by metabolic adaptations that promote weight regain.⁶ For patients with obesity who are unable to achieve or maintain sufficient weight loss to improve health outcomes with lifestyle modification alone, options include pharmacotherapy, devices, endoscopic bariatric therapies, and bariatric surgery.

Bariatric surgery is the most effective of these treatments, due to its association with significant and sustained weight loss, reduction in obesity-related comorbidities, and improved quality of life.^1,7 Furthermore, compared with usual care, bariatric surgery is associated with a reduced number of cardiovascular deaths, a lower incidence of cardiovascular events in adults with obesity, and a long-term reduction in overall mortality.^8-10

What are the options? Who is a candidate?

The 3 most common bariatric procedures in the United States are sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and laparoscopic adjustable gastric band (LAGB).¹¹ SG and RYGB are performed more often than the LAGB, consequent to greater efficacy and fewer complications.¹² Weight loss is maximal at 1 to 2 years, and is estimated to be 15% of total body weight for LAGB; 25% for SG; and 35% for RYGB.^13,14

Weight loss is estimated to be 15% of total body weight for the laparoscopic adjustable gastric band, 25% for sleeve gastrectomy, and 35% for Roux-en-Y gastric bypass.

Not all patients are candidates for bariatric surgery. Contraindications include chronic obstructive pulmonary disease or respiratory dysfunction, poor cardiac reserve, nonadherence to medical treatment, and severe psychological disorders.¹⁵ Because some patients have difficulty maintaining weight loss following bariatric surgery and, on average, patients regain at least some weight, patients must understand that long-term lifestyle changes and follow-up are critical to the success of bariatric surgery.¹⁶

When should bariatric surgery be considered?

American Heart Association/American College of Cardiology/The Obesity Society guidelines¹⁶ conceptualize 2 indications for bariatric surgery:

• adults with BMI ≥40
• adults with BMI ≥35 who have obesity-related comorbid conditions and are motivated to lose weight but have not responded to behavioral treatment, with or without pharmacotherapy, to achieve sufficient weight loss for target health goals.

American Association of Clinical Endocrinologists guidelines¹⁷ conceptualize 3 indications for bariatric surgery:

• adults with BMI ≥40
• adults with BMI ≥35 with 1 or more severe obesity-related complications
• adults with BMI 30-34.9 with diabetes or metabolic syndrome (evidence for this recommendation is limited).

Continue to: The 3 illustrative vignettes presented...

The 3 illustrative vignettes presented in this article offer examples of patients with obesity who could benefit from bariatric surgery. Each has been unable to achieve or maintain sufficient weight loss to improve health outcomes with nonsurgical interventions alone.

CASE 1

Sleep apnea persists despite weight loss

Robin W, a 50-year-old woman with class-II obesity (5’8”; 250 lb; BMI, 38 ), OSA requiring continuous positive airway pressure (CPAP), hyperlipidemia, hypertension, and iron-deficiency anemia secondary to menorrhagia, and taking an iron supplement, presents for weight management. She has lost 50 lb, reducing her BMI from 45.6 with behavioral modifications and pharmacotherapy, but she has been unsuccessful at achieving further weight loss despite a reduced-calorie diet and at least 30 minutes of physical activity most days.

Long-term lifestyle changes and follow-up are critical to the success of bariatric surgery.

Ms. W is frustrated that she has reached a weight plateau; she is motivated to lose more weight. Her goal is to improve her weight-related comorbid conditions and reduce her medication requirement. Despite the initial weight loss, she continues to require CPAP therapy for OSA and remains on 3 medications for hypertension. She does not have cardiac or respiratory disease, psychiatric diagnoses, or a history of gastroesophageal reflux disease (GERD).

Is bariatric surgery a reasonable option for Ms. W? If so, which procedure would you recommend?

Good option for Ms. W: Sleeve gastrectomy

It is reasonable to consider bariatric surgery—in particular, SG—for this patient with class-II obesity and multiple weight-related comorbid conditions because she has been unable to achieve further weight loss with more conservative measures.

Continue to: How does the procedure work?

How does the procedure work? SG removes a large portion of the stomach along the greater curvature, reducing the organ to approximately 15% to 25% of its original size.¹⁸ The procedure leaves the pyloric valve intact and does not involve removal or bypass of the intestines.

How appealing and successful is it? The majority of patients who undergo SG experience significant weight loss; studies report approximately 25% total body weight loss after 1 to 2 years.¹⁴ Furthermore, most patients with T2D experience resolution of, or improvement in, disease markers.¹⁹ Because SG leaves the pylorus intact, there are fewer restrictions on what a patient can eat after surgery, compared with RYGB. With further weight loss, Ms. W may experience improvement in, or resolution of, hypertension, hyperlipidemia, and OSA.

The SG procedure itself is simpler than some other bariatric procedures and presents less risk of malabsorption because the intestines are left intact. Patients who undergo SG report feeling less hungry because the fundus of the stomach, which secretes ghrelin (the so-called hunger hormone), is removed.^18,20

What are special considerations, including candidacy? Patients with GERD are not ideal candidates for this procedure because exacerbation of the disease is a potential associated adverse event. SG is a reasonable surgical option for Ms. W because the procedure is less likely to exacerbate her nutritional deficiency (iron-deficiency anemia), compared to RYGB, and she does not have a history of GERD.

What are the complications? Complications of SG occur at a lower rate than they do with RYGB, which is associated with a greater risk of nutritional deficiency.¹⁸ Common early complications of SG include leaking, bleeding, stenosis, GERD, and vomiting due to excessive eating. Late complications include stomach expansion by 12 months, leading to decreased restriction.¹⁵ Unlike RYGB and LAGB, SG is not reversible.

Continue to: CASE 2

CASE 2

Severe obesity, polypharmacy for type 2 diabetes

Anne P, a 42-year-old woman with class-III obesity (5’6”; 290 lb; BMI, 46.8 kg/m²), presents to discuss bariatric surgery. Comorbidities include T2D, for which she takes metformin, a glucagon-like peptide-1 (GLP-1) receptor agonist, and a sodium–glucose cotransporter-2 (SGLT-2) inhibitor; GERD; hypertension, for which she takes an angiotensin-converting enzyme inhibitor and a calcium-channel blocker; hyperlipidemia, for which she takes a statin; and osteoarthritis.

Roux-en-Y gastric bypass is effective for weight loss because patients eat smaller portions and cannot absorb all they eat.

Ms. P lost 30 pounds—reducing her BMI from 51.6—when the sulfonylurea and thiazolidinedione she was taking were switched to the GLP-1 receptor agonist and the SGLT2 inhibitor. She also made behavioral modifications, including 30 minutes a day of physical activity and a reduced-calorie meal plan under the guidance of a dietitian.

However, Ms. P has been unable to lose more weight or reduce her hemoglobin A_1c (HbA_1c) level below 8%. Her goal is to avoid the need to take insulin (which several members of her family take), lower her HbA_1c level, and decrease her medication requirement.

Ms. P does not have cardiac or respiratory disease or psychiatric diagnoses. Which surgical intervention would you recommend for her?

Good option for Ms. P: Roux-en-Y gastric bypass

RYGB is a reasonable option for a patient with class-III obesity and multiple comorbidities, including poorly controlled T2D and GERD, who has failed conservative measures but wants to lose more weight, reduce her HbA_1c, reduce her medication requirement, and avoid the need for insulin.

Continue to: How does the procedure work?

How does the procedure work? RYGB constructs a small pouch from the proximal portion of the stomach and attaches it directly to the jejunum, thus bypassing part of the stomach and duodenum. The procedure is effective for weight loss because it is both restrictive and malabsorptive: patients not only eat smaller portions, but cannot absorb all they eat. Other mechanisms attributed to RYGB that are hypothesized to promote weight loss include²¹:

• alteration of endogenous gut hormones, which promotes postprandial satiety
• increased levels of bile acids, which promotes alteration of the gut microbiome
• intestinal hypertrophy.

How successful is it? RYGB is associated with significant total body weight loss of approximately 35% at 2 years.⁹ The procedure has been shown to produce superior outcomes in reducing comorbid disease compared to other bariatric procedures or medical therapy alone. Of the procedures discussed in this article, RYGB is associated with the greatest reduction in triglycerides, HbA_1c, and use of diabetes medications, including insulin.²²

What are special considerations, including candidacy? For patients with mild or moderate T2D (calculated using the Individualized Metabolic Surgery Score [http://riskcalc.org/Metabolic_Surgery_Score/], which categorizes patients by number of diabetes medications, insulin use, duration of diabetes before surgery, and HbA_1c), RYGB is recommended over SG because it leads to greater long-term remission of T2D.

RYGB is associated with a lower rate of GERD than SG and can even alleviate GERD in patients who have the disease. Furthermore, for patients with limited pancreatic beta cell reserve, RYBG and SG have similarly low efficacy for T2D remission; SG is therefore recommended over RYGB in this specific circumstance, given its slightly lower risk profile.²³

What are the complications? Patients who undergo any bariatric surgical procedure require long-term follow-up and vitamin supplementation, but those who undergo RYGB require stricter dietary adherence after the procedure; lifelong vitamin (D, B₁₂, folic acid, and thiamine), iron, and calcium supplementation; and long-term follow-up to reduce the risk and severity of complications and to monitor for nutritional deficiencies.⁷ As such, patients who have shown poor adherence to medical treatment are not good candidates for the procedure.

Continue to: Early complications include...

Early complications include leak, stricture, obstruction, and failure of the staple partition of the upper stomach. Late complications include nutritional deficiencies, as noted, and ulceration of the anastomosis. Dumping syndrome (overly rapid transit of food from the stomach into the small intestine) can develop early or late; early dumping leads to osmotic diarrhea and abdominal cramping, and late dumping leads to reactive hypoglycemia.¹⁵

Most patients with T2D who undergo sleeve gastrectomy see resolution of, or improvement in, markers of diabetes.

Technically, RYGB is a reversible procedure, although generally it is reversed only in extreme circumstances.

CASE 3

Fatty liver disease, hesitation to undergo surgery

Walt Z, a 35 year-old-man with class-II obesity (5’10”; 265 lb; BMI, 38 kg/m²), T2D, and hepatic steatosis, presents for weight management. He has been able to lose modest weight over the years with behavioral modifications, but has been unsuccessful in maintaining that loss. He requests referral to a bariatric surgeon but is concerned about the permanence and invasiveness of most bariatric procedures.

Which surgical intervention would you recommend for this patient?

Good option for Mr. Z: Laparoscopic adjustable gastric band

Given that Mr. Z is a candidate for a surgical intervention but does not want a permanent or invasive procedure, LAGB is a reasonable option.

Continue to: How does the procedure work?

How does the procedure work? LAGB is a reversible procedure in which an inflatable band is placed around the fundus of the stomach to create a small pouch. The band can be adjusted to regulate food intake by adding or removing saline through a subcutaneous access port.

How appealing and successful is it? LAGB results in approximately 15% total body weight loss at 2 years.¹³ Because the procedure is purely restrictive, it carries a reduced risk of nutritional deficiency associated more commonly with malabsorptive procedures.

What are special considerations, including candidacy? As noted, Mr. Z expressed concern about the permanence and invasiveness of most bariatric procedures, and therefore wants to undergo a reversible procedure; LAGB can be a reasonable option for such a patient. Patients who want a reversible or minimally invasive procedure should also be made aware that endoscopic bariatric therapies and other devices are being developed to fill the treatment gap in the management of obesity.

What are the complications? Although LAGB is the least invasive procedure discussed here, it is associated with the highest rate of complications—most commonly, complications associated with the band itself (eg, nausea, vomiting, obstruction, band erosion or migration, esophageal dysmotility leading to acid reflux) and failure to lose weight.⁷ LAGB also requires more postoperative visits than other procedures, to optimize band tightness. A high number of bands are removed eventually because of complications or inadequate weight loss, or both.^13,24

Shared decision-making and dialogue are essential to overcome obstacles

Despite the known benefits of bariatric surgery, including greater reduction in the risk and severity of obesity-related comorbid conditions than seen with other interventions and a long-term reduction in overall mortality when compared with usual care, fewer than 1% of eligible patients undergo a weight-loss procedure.²⁵ Likely, this is due to:

• limited patient knowledge of the health benefits of surgery
• limited provider comfort recommending surgery
• inadequate insurance coverage, which might, in part, be due to a lack of prospective studies comparing various bariatric procedures.¹⁸

Continue to: Ultimately, the decision whether to undergo a bariatric procedure...

Ultimately, the decision whether to undergo a bariatric procedure, and which one(s) to consider, should be the product of a thorough conversation between patient and provider.

CORRESPONDENCE
Sarah R. Barenbaum, MD, Department of Internal Medicine, New York–Presbyterian Hospital/Weill Cornell Medical College, 530 East 70th Street, M-507, New York, NY 10021; srb9023@nyp.org

Patients with overweight and obesity are at increased risk of multiple morbidities, including cardiovascular disease, stroke, type 2 diabetes (T2D), osteoarthritis, obstructive sleep apnea (OSA), and all-cause mortality.¹ Even modest weight loss—5% to 10%—can lead to a clinically relevant reduction in this risk of disease.^2,3 The American Academy of Family Physicians recognizes obesity as a disease, and recommends screening of all adults for obesity and referral for those with body mass index (BMI)* ≥30 to intensive, multicomponent behavioral interventions.^4,5

For some patients, diet, exercise, and behavioral modifications are sufficient; for the great majority, however, weight loss achieved by lifestyle modification is counteracted by metabolic adaptations that promote weight regain.⁶ For patients with obesity who are unable to achieve or maintain sufficient weight loss to improve health outcomes with lifestyle modification alone, options include pharmacotherapy, devices, endoscopic bariatric therapies, and bariatric surgery.

Bariatric surgery is the most effective of these treatments, due to its association with significant and sustained weight loss, reduction in obesity-related comorbidities, and improved quality of life.^1,7 Furthermore, compared with usual care, bariatric surgery is associated with a reduced number of cardiovascular deaths, a lower incidence of cardiovascular events in adults with obesity, and a long-term reduction in overall mortality.^8-10

What are the options? Who is a candidate?

The 3 most common bariatric procedures in the United States are sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and laparoscopic adjustable gastric band (LAGB).¹¹ SG and RYGB are performed more often than the LAGB, consequent to greater efficacy and fewer complications.¹² Weight loss is maximal at 1 to 2 years, and is estimated to be 15% of total body weight for LAGB; 25% for SG; and 35% for RYGB.^13,14

Weight loss is estimated to be 15% of total body weight for the laparoscopic adjustable gastric band, 25% for sleeve gastrectomy, and 35% for Roux-en-Y gastric bypass.

Not all patients are candidates for bariatric surgery. Contraindications include chronic obstructive pulmonary disease or respiratory dysfunction, poor cardiac reserve, nonadherence to medical treatment, and severe psychological disorders.¹⁵ Because some patients have difficulty maintaining weight loss following bariatric surgery and, on average, patients regain at least some weight, patients must understand that long-term lifestyle changes and follow-up are critical to the success of bariatric surgery.¹⁶

When should bariatric surgery be considered?

American Heart Association/American College of Cardiology/The Obesity Society guidelines¹⁶ conceptualize 2 indications for bariatric surgery:

• adults with BMI ≥40
• adults with BMI ≥35 who have obesity-related comorbid conditions and are motivated to lose weight but have not responded to behavioral treatment, with or without pharmacotherapy, to achieve sufficient weight loss for target health goals.

American Association of Clinical Endocrinologists guidelines¹⁷ conceptualize 3 indications for bariatric surgery:

• adults with BMI ≥40
• adults with BMI ≥35 with 1 or more severe obesity-related complications
• adults with BMI 30-34.9 with diabetes or metabolic syndrome (evidence for this recommendation is limited).

Continue to: The 3 illustrative vignettes presented...

The 3 illustrative vignettes presented in this article offer examples of patients with obesity who could benefit from bariatric surgery. Each has been unable to achieve or maintain sufficient weight loss to improve health outcomes with nonsurgical interventions alone.

CASE 1

Sleep apnea persists despite weight loss

Robin W, a 50-year-old woman with class-II obesity (5’8”; 250 lb; BMI, 38 ), OSA requiring continuous positive airway pressure (CPAP), hyperlipidemia, hypertension, and iron-deficiency anemia secondary to menorrhagia, and taking an iron supplement, presents for weight management. She has lost 50 lb, reducing her BMI from 45.6 with behavioral modifications and pharmacotherapy, but she has been unsuccessful at achieving further weight loss despite a reduced-calorie diet and at least 30 minutes of physical activity most days.

Long-term lifestyle changes and follow-up are critical to the success of bariatric surgery.

Ms. W is frustrated that she has reached a weight plateau; she is motivated to lose more weight. Her goal is to improve her weight-related comorbid conditions and reduce her medication requirement. Despite the initial weight loss, she continues to require CPAP therapy for OSA and remains on 3 medications for hypertension. She does not have cardiac or respiratory disease, psychiatric diagnoses, or a history of gastroesophageal reflux disease (GERD).

Is bariatric surgery a reasonable option for Ms. W? If so, which procedure would you recommend?

Good option for Ms. W: Sleeve gastrectomy

It is reasonable to consider bariatric surgery—in particular, SG—for this patient with class-II obesity and multiple weight-related comorbid conditions because she has been unable to achieve further weight loss with more conservative measures.

Continue to: How does the procedure work?

How does the procedure work? SG removes a large portion of the stomach along the greater curvature, reducing the organ to approximately 15% to 25% of its original size.¹⁸ The procedure leaves the pyloric valve intact and does not involve removal or bypass of the intestines.

How appealing and successful is it? The majority of patients who undergo SG experience significant weight loss; studies report approximately 25% total body weight loss after 1 to 2 years.¹⁴ Furthermore, most patients with T2D experience resolution of, or improvement in, disease markers.¹⁹ Because SG leaves the pylorus intact, there are fewer restrictions on what a patient can eat after surgery, compared with RYGB. With further weight loss, Ms. W may experience improvement in, or resolution of, hypertension, hyperlipidemia, and OSA.

The SG procedure itself is simpler than some other bariatric procedures and presents less risk of malabsorption because the intestines are left intact. Patients who undergo SG report feeling less hungry because the fundus of the stomach, which secretes ghrelin (the so-called hunger hormone), is removed.^18,20

What are special considerations, including candidacy? Patients with GERD are not ideal candidates for this procedure because exacerbation of the disease is a potential associated adverse event. SG is a reasonable surgical option for Ms. W because the procedure is less likely to exacerbate her nutritional deficiency (iron-deficiency anemia), compared to RYGB, and she does not have a history of GERD.

What are the complications? Complications of SG occur at a lower rate than they do with RYGB, which is associated with a greater risk of nutritional deficiency.¹⁸ Common early complications of SG include leaking, bleeding, stenosis, GERD, and vomiting due to excessive eating. Late complications include stomach expansion by 12 months, leading to decreased restriction.¹⁵ Unlike RYGB and LAGB, SG is not reversible.

Continue to: CASE 2

CASE 2

Severe obesity, polypharmacy for type 2 diabetes

Anne P, a 42-year-old woman with class-III obesity (5’6”; 290 lb; BMI, 46.8 kg/m²), presents to discuss bariatric surgery. Comorbidities include T2D, for which she takes metformin, a glucagon-like peptide-1 (GLP-1) receptor agonist, and a sodium–glucose cotransporter-2 (SGLT-2) inhibitor; GERD; hypertension, for which she takes an angiotensin-converting enzyme inhibitor and a calcium-channel blocker; hyperlipidemia, for which she takes a statin; and osteoarthritis.

Roux-en-Y gastric bypass is effective for weight loss because patients eat smaller portions and cannot absorb all they eat.

Ms. P lost 30 pounds—reducing her BMI from 51.6—when the sulfonylurea and thiazolidinedione she was taking were switched to the GLP-1 receptor agonist and the SGLT2 inhibitor. She also made behavioral modifications, including 30 minutes a day of physical activity and a reduced-calorie meal plan under the guidance of a dietitian.

However, Ms. P has been unable to lose more weight or reduce her hemoglobin A_1c (HbA_1c) level below 8%. Her goal is to avoid the need to take insulin (which several members of her family take), lower her HbA_1c level, and decrease her medication requirement.

Ms. P does not have cardiac or respiratory disease or psychiatric diagnoses. Which surgical intervention would you recommend for her?

Good option for Ms. P: Roux-en-Y gastric bypass

RYGB is a reasonable option for a patient with class-III obesity and multiple comorbidities, including poorly controlled T2D and GERD, who has failed conservative measures but wants to lose more weight, reduce her HbA_1c, reduce her medication requirement, and avoid the need for insulin.

Continue to: How does the procedure work?

How does the procedure work? RYGB constructs a small pouch from the proximal portion of the stomach and attaches it directly to the jejunum, thus bypassing part of the stomach and duodenum. The procedure is effective for weight loss because it is both restrictive and malabsorptive: patients not only eat smaller portions, but cannot absorb all they eat. Other mechanisms attributed to RYGB that are hypothesized to promote weight loss include²¹:

• alteration of endogenous gut hormones, which promotes postprandial satiety
• increased levels of bile acids, which promotes alteration of the gut microbiome
• intestinal hypertrophy.

How successful is it? RYGB is associated with significant total body weight loss of approximately 35% at 2 years.⁹ The procedure has been shown to produce superior outcomes in reducing comorbid disease compared to other bariatric procedures or medical therapy alone. Of the procedures discussed in this article, RYGB is associated with the greatest reduction in triglycerides, HbA_1c, and use of diabetes medications, including insulin.²²

What are special considerations, including candidacy? For patients with mild or moderate T2D (calculated using the Individualized Metabolic Surgery Score [http://riskcalc.org/Metabolic_Surgery_Score/], which categorizes patients by number of diabetes medications, insulin use, duration of diabetes before surgery, and HbA_1c), RYGB is recommended over SG because it leads to greater long-term remission of T2D.

RYGB is associated with a lower rate of GERD than SG and can even alleviate GERD in patients who have the disease. Furthermore, for patients with limited pancreatic beta cell reserve, RYBG and SG have similarly low efficacy for T2D remission; SG is therefore recommended over RYGB in this specific circumstance, given its slightly lower risk profile.²³

What are the complications? Patients who undergo any bariatric surgical procedure require long-term follow-up and vitamin supplementation, but those who undergo RYGB require stricter dietary adherence after the procedure; lifelong vitamin (D, B₁₂, folic acid, and thiamine), iron, and calcium supplementation; and long-term follow-up to reduce the risk and severity of complications and to monitor for nutritional deficiencies.⁷ As such, patients who have shown poor adherence to medical treatment are not good candidates for the procedure.

Continue to: Early complications include...

Early complications include leak, stricture, obstruction, and failure of the staple partition of the upper stomach. Late complications include nutritional deficiencies, as noted, and ulceration of the anastomosis. Dumping syndrome (overly rapid transit of food from the stomach into the small intestine) can develop early or late; early dumping leads to osmotic diarrhea and abdominal cramping, and late dumping leads to reactive hypoglycemia.¹⁵

Most patients with T2D who undergo sleeve gastrectomy see resolution of, or improvement in, markers of diabetes.

Technically, RYGB is a reversible procedure, although generally it is reversed only in extreme circumstances.

CASE 3

Fatty liver disease, hesitation to undergo surgery

Walt Z, a 35 year-old-man with class-II obesity (5’10”; 265 lb; BMI, 38 kg/m²), T2D, and hepatic steatosis, presents for weight management. He has been able to lose modest weight over the years with behavioral modifications, but has been unsuccessful in maintaining that loss. He requests referral to a bariatric surgeon but is concerned about the permanence and invasiveness of most bariatric procedures.

Which surgical intervention would you recommend for this patient?

Good option for Mr. Z: Laparoscopic adjustable gastric band

Given that Mr. Z is a candidate for a surgical intervention but does not want a permanent or invasive procedure, LAGB is a reasonable option.

Continue to: How does the procedure work?

How does the procedure work? LAGB is a reversible procedure in which an inflatable band is placed around the fundus of the stomach to create a small pouch. The band can be adjusted to regulate food intake by adding or removing saline through a subcutaneous access port.

How appealing and successful is it? LAGB results in approximately 15% total body weight loss at 2 years.¹³ Because the procedure is purely restrictive, it carries a reduced risk of nutritional deficiency associated more commonly with malabsorptive procedures.

What are special considerations, including candidacy? As noted, Mr. Z expressed concern about the permanence and invasiveness of most bariatric procedures, and therefore wants to undergo a reversible procedure; LAGB can be a reasonable option for such a patient. Patients who want a reversible or minimally invasive procedure should also be made aware that endoscopic bariatric therapies and other devices are being developed to fill the treatment gap in the management of obesity.

What are the complications? Although LAGB is the least invasive procedure discussed here, it is associated with the highest rate of complications—most commonly, complications associated with the band itself (eg, nausea, vomiting, obstruction, band erosion or migration, esophageal dysmotility leading to acid reflux) and failure to lose weight.⁷ LAGB also requires more postoperative visits than other procedures, to optimize band tightness. A high number of bands are removed eventually because of complications or inadequate weight loss, or both.^13,24

Shared decision-making and dialogue are essential to overcome obstacles

Despite the known benefits of bariatric surgery, including greater reduction in the risk and severity of obesity-related comorbid conditions than seen with other interventions and a long-term reduction in overall mortality when compared with usual care, fewer than 1% of eligible patients undergo a weight-loss procedure.²⁵ Likely, this is due to:

• limited patient knowledge of the health benefits of surgery
• limited provider comfort recommending surgery
• inadequate insurance coverage, which might, in part, be due to a lack of prospective studies comparing various bariatric procedures.¹⁸

Continue to: Ultimately, the decision whether to undergo a bariatric procedure...

Ultimately, the decision whether to undergo a bariatric procedure, and which one(s) to consider, should be the product of a thorough conversation between patient and provider.

CORRESPONDENCE
Sarah R. Barenbaum, MD, Department of Internal Medicine, New York–Presbyterian Hospital/Weill Cornell Medical College, 530 East 70th Street, M-507, New York, NY 10021; srb9023@nyp.org

Patients with overweight and obesity are at increased risk of multiple morbidities, including cardiovascular disease, stroke, type 2 diabetes (T2D), osteoarthritis, obstructive sleep apnea (OSA), and all-cause mortality.¹ Even modest weight loss—5% to 10%—can lead to a clinically relevant reduction in this risk of disease.^2,3 The American Academy of Family Physicians recognizes obesity as a disease, and recommends screening of all adults for obesity and referral for those with body mass index (BMI)* ≥30 to intensive, multicomponent behavioral interventions.^4,5

For some patients, diet, exercise, and behavioral modifications are sufficient; for the great majority, however, weight loss achieved by lifestyle modification is counteracted by metabolic adaptations that promote weight regain.⁶ For patients with obesity who are unable to achieve or maintain sufficient weight loss to improve health outcomes with lifestyle modification alone, options include pharmacotherapy, devices, endoscopic bariatric therapies, and bariatric surgery.

Bariatric surgery is the most effective of these treatments, due to its association with significant and sustained weight loss, reduction in obesity-related comorbidities, and improved quality of life.^1,7 Furthermore, compared with usual care, bariatric surgery is associated with a reduced number of cardiovascular deaths, a lower incidence of cardiovascular events in adults with obesity, and a long-term reduction in overall mortality.^8-10

What are the options? Who is a candidate?

The 3 most common bariatric procedures in the United States are sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and laparoscopic adjustable gastric band (LAGB).¹¹ SG and RYGB are performed more often than the LAGB, consequent to greater efficacy and fewer complications.¹² Weight loss is maximal at 1 to 2 years, and is estimated to be 15% of total body weight for LAGB; 25% for SG; and 35% for RYGB.^13,14

Weight loss is estimated to be 15% of total body weight for the laparoscopic adjustable gastric band, 25% for sleeve gastrectomy, and 35% for Roux-en-Y gastric bypass.

Not all patients are candidates for bariatric surgery. Contraindications include chronic obstructive pulmonary disease or respiratory dysfunction, poor cardiac reserve, nonadherence to medical treatment, and severe psychological disorders.¹⁵ Because some patients have difficulty maintaining weight loss following bariatric surgery and, on average, patients regain at least some weight, patients must understand that long-term lifestyle changes and follow-up are critical to the success of bariatric surgery.¹⁶

When should bariatric surgery be considered?

American Heart Association/American College of Cardiology/The Obesity Society guidelines¹⁶ conceptualize 2 indications for bariatric surgery:

• adults with BMI ≥40
• adults with BMI ≥35 who have obesity-related comorbid conditions and are motivated to lose weight but have not responded to behavioral treatment, with or without pharmacotherapy, to achieve sufficient weight loss for target health goals.

American Association of Clinical Endocrinologists guidelines¹⁷ conceptualize 3 indications for bariatric surgery:

• adults with BMI ≥40
• adults with BMI ≥35 with 1 or more severe obesity-related complications
• adults with BMI 30-34.9 with diabetes or metabolic syndrome (evidence for this recommendation is limited).

Continue to: The 3 illustrative vignettes presented...

The 3 illustrative vignettes presented in this article offer examples of patients with obesity who could benefit from bariatric surgery. Each has been unable to achieve or maintain sufficient weight loss to improve health outcomes with nonsurgical interventions alone.

CASE 1

Sleep apnea persists despite weight loss

Robin W, a 50-year-old woman with class-II obesity (5’8”; 250 lb; BMI, 38 ), OSA requiring continuous positive airway pressure (CPAP), hyperlipidemia, hypertension, and iron-deficiency anemia secondary to menorrhagia, and taking an iron supplement, presents for weight management. She has lost 50 lb, reducing her BMI from 45.6 with behavioral modifications and pharmacotherapy, but she has been unsuccessful at achieving further weight loss despite a reduced-calorie diet and at least 30 minutes of physical activity most days.

Long-term lifestyle changes and follow-up are critical to the success of bariatric surgery.

Ms. W is frustrated that she has reached a weight plateau; she is motivated to lose more weight. Her goal is to improve her weight-related comorbid conditions and reduce her medication requirement. Despite the initial weight loss, she continues to require CPAP therapy for OSA and remains on 3 medications for hypertension. She does not have cardiac or respiratory disease, psychiatric diagnoses, or a history of gastroesophageal reflux disease (GERD).

Is bariatric surgery a reasonable option for Ms. W? If so, which procedure would you recommend?

Good option for Ms. W: Sleeve gastrectomy

It is reasonable to consider bariatric surgery—in particular, SG—for this patient with class-II obesity and multiple weight-related comorbid conditions because she has been unable to achieve further weight loss with more conservative measures.

Continue to: How does the procedure work?

How does the procedure work? SG removes a large portion of the stomach along the greater curvature, reducing the organ to approximately 15% to 25% of its original size.¹⁸ The procedure leaves the pyloric valve intact and does not involve removal or bypass of the intestines.

How appealing and successful is it? The majority of patients who undergo SG experience significant weight loss; studies report approximately 25% total body weight loss after 1 to 2 years.¹⁴ Furthermore, most patients with T2D experience resolution of, or improvement in, disease markers.¹⁹ Because SG leaves the pylorus intact, there are fewer restrictions on what a patient can eat after surgery, compared with RYGB. With further weight loss, Ms. W may experience improvement in, or resolution of, hypertension, hyperlipidemia, and OSA.

The SG procedure itself is simpler than some other bariatric procedures and presents less risk of malabsorption because the intestines are left intact. Patients who undergo SG report feeling less hungry because the fundus of the stomach, which secretes ghrelin (the so-called hunger hormone), is removed.^18,20

What are special considerations, including candidacy? Patients with GERD are not ideal candidates for this procedure because exacerbation of the disease is a potential associated adverse event. SG is a reasonable surgical option for Ms. W because the procedure is less likely to exacerbate her nutritional deficiency (iron-deficiency anemia), compared to RYGB, and she does not have a history of GERD.

What are the complications? Complications of SG occur at a lower rate than they do with RYGB, which is associated with a greater risk of nutritional deficiency.¹⁸ Common early complications of SG include leaking, bleeding, stenosis, GERD, and vomiting due to excessive eating. Late complications include stomach expansion by 12 months, leading to decreased restriction.¹⁵ Unlike RYGB and LAGB, SG is not reversible.

Continue to: CASE 2

CASE 2

Severe obesity, polypharmacy for type 2 diabetes

Anne P, a 42-year-old woman with class-III obesity (5’6”; 290 lb; BMI, 46.8 kg/m²), presents to discuss bariatric surgery. Comorbidities include T2D, for which she takes metformin, a glucagon-like peptide-1 (GLP-1) receptor agonist, and a sodium–glucose cotransporter-2 (SGLT-2) inhibitor; GERD; hypertension, for which she takes an angiotensin-converting enzyme inhibitor and a calcium-channel blocker; hyperlipidemia, for which she takes a statin; and osteoarthritis.

Roux-en-Y gastric bypass is effective for weight loss because patients eat smaller portions and cannot absorb all they eat.

Ms. P lost 30 pounds—reducing her BMI from 51.6—when the sulfonylurea and thiazolidinedione she was taking were switched to the GLP-1 receptor agonist and the SGLT2 inhibitor. She also made behavioral modifications, including 30 minutes a day of physical activity and a reduced-calorie meal plan under the guidance of a dietitian.

However, Ms. P has been unable to lose more weight or reduce her hemoglobin A_1c (HbA_1c) level below 8%. Her goal is to avoid the need to take insulin (which several members of her family take), lower her HbA_1c level, and decrease her medication requirement.

Ms. P does not have cardiac or respiratory disease or psychiatric diagnoses. Which surgical intervention would you recommend for her?

Good option for Ms. P: Roux-en-Y gastric bypass

RYGB is a reasonable option for a patient with class-III obesity and multiple comorbidities, including poorly controlled T2D and GERD, who has failed conservative measures but wants to lose more weight, reduce her HbA_1c, reduce her medication requirement, and avoid the need for insulin.

Continue to: How does the procedure work?

How does the procedure work? RYGB constructs a small pouch from the proximal portion of the stomach and attaches it directly to the jejunum, thus bypassing part of the stomach and duodenum. The procedure is effective for weight loss because it is both restrictive and malabsorptive: patients not only eat smaller portions, but cannot absorb all they eat. Other mechanisms attributed to RYGB that are hypothesized to promote weight loss include²¹:

• alteration of endogenous gut hormones, which promotes postprandial satiety
• increased levels of bile acids, which promotes alteration of the gut microbiome
• intestinal hypertrophy.

How successful is it? RYGB is associated with significant total body weight loss of approximately 35% at 2 years.⁹ The procedure has been shown to produce superior outcomes in reducing comorbid disease compared to other bariatric procedures or medical therapy alone. Of the procedures discussed in this article, RYGB is associated with the greatest reduction in triglycerides, HbA_1c, and use of diabetes medications, including insulin.²²

What are special considerations, including candidacy? For patients with mild or moderate T2D (calculated using the Individualized Metabolic Surgery Score [http://riskcalc.org/Metabolic_Surgery_Score/], which categorizes patients by number of diabetes medications, insulin use, duration of diabetes before surgery, and HbA_1c), RYGB is recommended over SG because it leads to greater long-term remission of T2D.

RYGB is associated with a lower rate of GERD than SG and can even alleviate GERD in patients who have the disease. Furthermore, for patients with limited pancreatic beta cell reserve, RYBG and SG have similarly low efficacy for T2D remission; SG is therefore recommended over RYGB in this specific circumstance, given its slightly lower risk profile.²³

What are the complications? Patients who undergo any bariatric surgical procedure require long-term follow-up and vitamin supplementation, but those who undergo RYGB require stricter dietary adherence after the procedure; lifelong vitamin (D, B₁₂, folic acid, and thiamine), iron, and calcium supplementation; and long-term follow-up to reduce the risk and severity of complications and to monitor for nutritional deficiencies.⁷ As such, patients who have shown poor adherence to medical treatment are not good candidates for the procedure.

Continue to: Early complications include...

Early complications include leak, stricture, obstruction, and failure of the staple partition of the upper stomach. Late complications include nutritional deficiencies, as noted, and ulceration of the anastomosis. Dumping syndrome (overly rapid transit of food from the stomach into the small intestine) can develop early or late; early dumping leads to osmotic diarrhea and abdominal cramping, and late dumping leads to reactive hypoglycemia.¹⁵

Most patients with T2D who undergo sleeve gastrectomy see resolution of, or improvement in, markers of diabetes.

Technically, RYGB is a reversible procedure, although generally it is reversed only in extreme circumstances.

CASE 3

Fatty liver disease, hesitation to undergo surgery

Walt Z, a 35 year-old-man with class-II obesity (5’10”; 265 lb; BMI, 38 kg/m²), T2D, and hepatic steatosis, presents for weight management. He has been able to lose modest weight over the years with behavioral modifications, but has been unsuccessful in maintaining that loss. He requests referral to a bariatric surgeon but is concerned about the permanence and invasiveness of most bariatric procedures.

Which surgical intervention would you recommend for this patient?

Good option for Mr. Z: Laparoscopic adjustable gastric band

Given that Mr. Z is a candidate for a surgical intervention but does not want a permanent or invasive procedure, LAGB is a reasonable option.

Continue to: How does the procedure work?

How does the procedure work? LAGB is a reversible procedure in which an inflatable band is placed around the fundus of the stomach to create a small pouch. The band can be adjusted to regulate food intake by adding or removing saline through a subcutaneous access port.

How appealing and successful is it? LAGB results in approximately 15% total body weight loss at 2 years.¹³ Because the procedure is purely restrictive, it carries a reduced risk of nutritional deficiency associated more commonly with malabsorptive procedures.

What are special considerations, including candidacy? As noted, Mr. Z expressed concern about the permanence and invasiveness of most bariatric procedures, and therefore wants to undergo a reversible procedure; LAGB can be a reasonable option for such a patient. Patients who want a reversible or minimally invasive procedure should also be made aware that endoscopic bariatric therapies and other devices are being developed to fill the treatment gap in the management of obesity.

What are the complications? Although LAGB is the least invasive procedure discussed here, it is associated with the highest rate of complications—most commonly, complications associated with the band itself (eg, nausea, vomiting, obstruction, band erosion or migration, esophageal dysmotility leading to acid reflux) and failure to lose weight.⁷ LAGB also requires more postoperative visits than other procedures, to optimize band tightness. A high number of bands are removed eventually because of complications or inadequate weight loss, or both.^13,24

Shared decision-making and dialogue are essential to overcome obstacles

Despite the known benefits of bariatric surgery, including greater reduction in the risk and severity of obesity-related comorbid conditions than seen with other interventions and a long-term reduction in overall mortality when compared with usual care, fewer than 1% of eligible patients undergo a weight-loss procedure.²⁵ Likely, this is due to:

• limited patient knowledge of the health benefits of surgery
• limited provider comfort recommending surgery
• inadequate insurance coverage, which might, in part, be due to a lack of prospective studies comparing various bariatric procedures.¹⁸

Continue to: Ultimately, the decision whether to undergo a bariatric procedure...

Ultimately, the decision whether to undergo a bariatric procedure, and which one(s) to consider, should be the product of a thorough conversation between patient and provider.

CORRESPONDENCE
Sarah R. Barenbaum, MD, Department of Internal Medicine, New York–Presbyterian Hospital/Weill Cornell Medical College, 530 East 70th Street, M-507, New York, NY 10021; srb9023@nyp.org

Patients With High Blood Pressure Should Undergo Clock Drawing Test

A clock drawing test for detecting cognitive dysfunction should be conducted routinely in patients with high blood pressure, according to researchers.

Patients with high blood pressure who have impaired cognitive function are at increased risk of developing dementia within five years. Despite this known link, cognitive function is not routinely measured in patients with high blood pressure.

“The ability to draw the numbers of a clock and a particular time is an easy way to find out if a patient with high blood pressure has cognitive impairment,” said Augusto Vicario, MD, a cardiologist at the Cardiovascular Institute of Buenos Aires. “Identifying these patients provides the opportunity to intervene before dementia develops.”

The Heart-Brain Study in Argentina evaluated the usefulness of the clock drawing test, compared with the Mini-Mental State Examination (MMSE), to detect cognitive impairment in 1,414 adults with high blood pressure recruited from 18 cardiology centers in Argentina. The population’s average blood pressure was 144/84 mm Hg, average age was 60, and 62% were women.

For the clock drawing test, patients were given a piece of paper with a circle on it (diameter, 10 cm). They were asked to write the numbers of the clock in the correct positions inside the circle and draw hands on the clock indicating the time “20 to four.” Patients were scored as having normal cognition or moderate or severe cognitive impairment.

The researchers found a higher prevalence of cognitive impairment with the clock drawing test (36%), compared with the MMSE (21%). Three of 10 patients who had a normal MMSE score had an abnormal clock drawing result. The disparity in results between the two tests was greatest in middle-aged patients.

“Untreated high blood pressure silently and progressively damages the arteries in the subcortex of the brain and stops communication between the subcortex and frontal lobe,” said Dr. Vicario. “This disconnect leads to impaired executive functions such as planning, visuospatial abilities, remembering details, and decision-making. The clock drawing test is known to evaluate executive functions. The MMSE evaluates several other cognitive abilities but is weakly correlated with executive functions.

“Our study suggests that the clock drawing test should be preferred over the MMSE for early detection of executive dysfunction in patients with high blood pressure, particularly in middle age. We think the score on the clock drawing test can be considered a surrogate measure of silent vascular damage in the brain and identifies patients at greater risk of developing dementia. In our study, more than one-third of patients were at risk.

“The clock drawing test should be adopted as a routine screening tool for cognitive decline in patients with high blood pressure. Further studies are needed to determine whether lowering blood pressure can prevent progression to dementia,” Dr. Vicario concluded.

Short Sleep Associated With Doubled Risk of Cardiovascular Disease

Middle-aged men who sleep for five hours or fewer per night have twice the risk of developing a major cardiovascular event during the following two decades, compared with men who sleep for seven to eight hours, according to a study.

“For people with busy lives, sleeping may feel like a waste of time, but our study suggests that short sleep could be linked with future cardiovascular disease,” said Moa Bengtsson of the University of Gothenburg, Sweden.

Previous studies have generated conflicting evidence on whether short sleep is associated with a greater chance of having a future cardiovascular event. This study investigated this relationship in 50-year-old men.

In 1993, 50% of all men born in 1943 and living in Gothenburg were randomly selected to participate in the study. Of the 1,463 invited, 798 (55%) men agreed to take part. Participants underwent a physical examination and completed a questionnaire on current health conditions, average sleep duration, physical activity, and smoking. The men were divided into four groups according to their self-estimated average sleep duration at the start of the study: five or fewer hours, six hours, seven to eight hours (considered normal sleep duration), and more than eight hours.

Participants were followed up for 21 years for the occurrence of major cardiovascular events, which included heart attack, stroke, hospitalization due to heart failure, coronary revascularization, or death from cardiovascular disease. Data on cardiovascular events were collected from medical records, the Swedish Hospital Discharge Registry, and the Swedish Cause of Death Register.

Men with incomplete data on sleep duration, incomplete follow-up information, or who had a major cardiovascular event before the start of the study were excluded, leaving a total of 759 men for the analyses.

High blood pressure, diabetes, obesity, current smoking, low physical activity, and poor sleep quality were more common in men who slept for five or fewer hours per night, compared with those who slept for seven to eight hours.

Compared with those with normal sleep duration, men who slept for five or fewer hours per night had a twofold higher risk of having a major cardiovascular event by age 71. The risk remained doubled after adjusting for cardiovascular risk factors at the start of the study, including obesity, diabetes, and smoking.

“Men with the shortest sleep duration at the age of 50 were twice as likely to have had a cardiovascular event by age 71 as those who slept a normal amount, even when other risk factors were taken into account,” said Ms. Bengtsson.

“In our study, the magnitude of increased cardiovascular risk associated with insufficient sleep is similar to that of smoking or having diabetes at age 50. This was an observational study, so, based on our findings, we cannot conclude that short sleep causes cardiovascular disease or say definitively that sleeping more will reduce risk. However, the findings do suggest that sleep is important, and that should be a wake-up call to all of us.”

How Long Is a Good Night’s Sleep?

Researchers have found that a sweet spot of six to eight hours’ sleep per night is most beneficial for heart health. More or less sleep is detrimental.

“We spend one-third of our lives sleeping, yet we know little about the impact of this biologic need on the cardiovascular system,” said Epameinondas Fountas, MD, of the Onassis Cardiac Surgery Centre in Athens.

The study investigated the relationship between sleep duration and cardiovascular disease using a meta-analysis that included 11 prospective studies published within the past five years of more than one million adults without cardiovascular disease.

Two groups, one with short (ie, fewer than six hours) and another with long (ie, more than eight hours) nightly sleep duration, were compared with the reference group (ie, six to eight hours’ sleep).

Short and long sleepers had a greater risk of developing or dying from coronary artery disease or stroke. Compared with adults who slept for six to eight hours per night, short and long sleepers had 11% and 33% greater risks, respectively, of developing or dying from coronary artery disease or stroke during an average follow-up of 9.3 years.

“Our findings suggest that too much or too little sleep may be bad for the heart,” said Dr. Fountas. “More research is needed to clarify exactly why, but we do know that sleep influences biologic processes like glucose metabolism, blood pressure, and inflammation, all of which have an impact on cardiovascular disease.”

A strength of the current analysis is that only prospective studies were included, noted Dr. Fountas. This technique avoids recall bias.

“Having the odd short night or lie-in is unlikely to be detrimental to health, but evidence is accumulating that prolonged nightly sleep deprivation or excessive sleeping should be avoided,” said Dr. Fountas. “The good news is that there are plenty of ways to get into the habit of getting six to eight hours a night: for example, by going to bed and getting up at the same time every day, avoiding alcohol and caffeine before bed, eating healthily, and being physically active. Getting the right amount of sleep is an important part of a healthy lifestyle.”

Four in 10 Patients With Atrial Fibrillation Have Unrecognized Brain Damage

Four out of 10 patients with atrial fibrillation but no history of stroke or transient ischemic attack have previously unrecognized brain damage, according to the first results of the Swiss Atrial Fibrillation Cohort Study (Swiss-AF).

“Our results suggest that clinically unrecognized brain damage may explain the association between dementia and atrial fibrillation in patients without prior stroke,” said David Conen, MD, MPH, Associate Professor of Cardiology at McMaster University in Hamilton, Canada.

Patients with atrial fibrillation have a significantly increased risk of stroke, which is why most are treated with oral anticoagulation. This increased stroke risk is probably the main reason why patients with atrial fibrillation also face an increased risk of cognitive dysfunction and dementia. The relationship between atrial fibrillation and dementia has also been shown among patients without prior strokes, however, meaning that additional mechanisms must be involved. Clarifying the mechanisms by which atrial fibrillation increases the risk of cognitive dysfunction and dementia is a first step towards developing preventive measures.

Swiss-AF is a prospective, observational study designed to pinpoint the mechanisms of cognitive decline in patients with atrial fibrillation. Dr. Conen’s analysis investigated the prevalence of silent brain damage in patients with atrial fibrillation.

The study enrolled 2,415 patients older than 65 with atrial fibrillation between 2014 and 2017 from 14 centers in Switzerland. All patients without contraindications underwent standardized brain MRI, and the images were analyzed in a central core laboratory. Scans were available in 1,736 patients. Of those patients, 347 (20%) had a history of stroke or transient ischemic attack and were excluded from the analysis.

The final analysis included 1,389 patients with atrial fibrillation but no history of stroke or transient ischemic attack. The average age of participants was 72, and 26% were women. The scans showed that 569 (41%) patients had at least one type of previously unrecognized brain damage: 207 (15%) had a cerebral infarct, 269 (19%) had microbleeds, and 222 (16%) had lacunes.

“Four in 10 patients with atrial fibrillation but no history of stroke or transient ischemic attack had clinically unrecognized silent brain lesions,” said Dr. Conen. “This brain damage could trigger cognitive decline.”

Most study participants (1,234; 89%) were treated with oral anticoagulants. Stefan Osswald, MD, Chief of Cardiology at University Hospital Basel in Switzerland, noted that the cross-sectional analysis looked at the data at a single point in time and cannot address the question of whether the cerebral infarcts and other brain lesions occurred before or after initiation of oral anticoagulation. “The findings nevertheless raise the issue that oral anticoagulation might not prevent all brain damage in patients with atrial fibrillation,” he said.

“All Swiss-AF participants underwent extensive cognitive testing. These data will be analyzed to see whether patients with silent brain lesions also have impaired cognitive function,” said Dr. Conen. Collaborations with other study groups will help determine whether these findings are specific to patients with atrial fibrillation.

Impaired Mental Status Doubles Elderly’s Risk of Death After Heart Attack

Impaired mental status is associated with a doubled risk of death one year after a heart attack in elderly patients, according to researchers.

“Cardiologists should consider conducting simple tests to assess mental status in elderly people after a heart attack,” said Farzin Beygui, MD, hospital practitioner at Caen University Hospital in France. “Patients with reduced mental status can then receive more intensive management such as regular follow-up appointments with their general practitioners or nurses, more specific assessment for an early diagnosis of dementia, and tailored therapy.”

The risks of dementia, Alzheimer’s disease, confusion, and delirium increase with age. Elderly people are also at higher risk of having a heart attack and dying afterwards. People aged 75 and older account for approximately one-third of heart attack admissions and more than half of those dying in the hospital after admission for a heart attack. Until now, it was not known whether impaired mental status affected the prognosis of elderly patients with heart attack.

This study assessed the impact of mental status on the risk of death in 600 patients age 75 and above consecutively admitted for heart attack and followed up for at least one year. Mental status was assessed using the Mini-Mental State Examination (MMSE) and the Confusion Assessment Method (CAM).Cognitive impairment was detected in 174 (29%) patients. Patients with impaired mental function were more than twice as likely to be dead one year after their heart attack than those with healthy mental function. The association was independent of other potential predictors of death such as age, sex, invasive treatment, type of myocardial infarction, heart failure, and severity of the heart attack.

Impaired mental status was also associated with a nearly fourfold higher rate of bleeding complications while in the hospital and a more than twofold higher risk of being readmitted to the hospital for cardiovascular causes within three months after discharge.

“Almost one-third of elderly heart attack patients in our study had reduced mental capacity,” said Dr. Beygui. “These patients had higher risks of bleeding, rehospitalization, and death. This may be because they forget to take their medicines or take them more than prescribed, rather than because of poor cognitive function itself.

“Assessing mental status is a simple way to identify elderly patients at particularly high risk of poor outcomes following a heart attack. Identifying these patients may help us target treatment to those who need it most.”

Patients With High Blood Pressure Should Undergo Clock Drawing Test

A clock drawing test for detecting cognitive dysfunction should be conducted routinely in patients with high blood pressure, according to researchers.

Patients with high blood pressure who have impaired cognitive function are at increased risk of developing dementia within five years. Despite this known link, cognitive function is not routinely measured in patients with high blood pressure.

“The ability to draw the numbers of a clock and a particular time is an easy way to find out if a patient with high blood pressure has cognitive impairment,” said Augusto Vicario, MD, a cardiologist at the Cardiovascular Institute of Buenos Aires. “Identifying these patients provides the opportunity to intervene before dementia develops.”

The Heart-Brain Study in Argentina evaluated the usefulness of the clock drawing test, compared with the Mini-Mental State Examination (MMSE), to detect cognitive impairment in 1,414 adults with high blood pressure recruited from 18 cardiology centers in Argentina. The population’s average blood pressure was 144/84 mm Hg, average age was 60, and 62% were women.

For the clock drawing test, patients were given a piece of paper with a circle on it (diameter, 10 cm). They were asked to write the numbers of the clock in the correct positions inside the circle and draw hands on the clock indicating the time “20 to four.” Patients were scored as having normal cognition or moderate or severe cognitive impairment.

The researchers found a higher prevalence of cognitive impairment with the clock drawing test (36%), compared with the MMSE (21%). Three of 10 patients who had a normal MMSE score had an abnormal clock drawing result. The disparity in results between the two tests was greatest in middle-aged patients.

“Untreated high blood pressure silently and progressively damages the arteries in the subcortex of the brain and stops communication between the subcortex and frontal lobe,” said Dr. Vicario. “This disconnect leads to impaired executive functions such as planning, visuospatial abilities, remembering details, and decision-making. The clock drawing test is known to evaluate executive functions. The MMSE evaluates several other cognitive abilities but is weakly correlated with executive functions.

“Our study suggests that the clock drawing test should be preferred over the MMSE for early detection of executive dysfunction in patients with high blood pressure, particularly in middle age. We think the score on the clock drawing test can be considered a surrogate measure of silent vascular damage in the brain and identifies patients at greater risk of developing dementia. In our study, more than one-third of patients were at risk.

“The clock drawing test should be adopted as a routine screening tool for cognitive decline in patients with high blood pressure. Further studies are needed to determine whether lowering blood pressure can prevent progression to dementia,” Dr. Vicario concluded.

Short Sleep Associated With Doubled Risk of Cardiovascular Disease

Middle-aged men who sleep for five hours or fewer per night have twice the risk of developing a major cardiovascular event during the following two decades, compared with men who sleep for seven to eight hours, according to a study.

“For people with busy lives, sleeping may feel like a waste of time, but our study suggests that short sleep could be linked with future cardiovascular disease,” said Moa Bengtsson of the University of Gothenburg, Sweden.

Previous studies have generated conflicting evidence on whether short sleep is associated with a greater chance of having a future cardiovascular event. This study investigated this relationship in 50-year-old men.

In 1993, 50% of all men born in 1943 and living in Gothenburg were randomly selected to participate in the study. Of the 1,463 invited, 798 (55%) men agreed to take part. Participants underwent a physical examination and completed a questionnaire on current health conditions, average sleep duration, physical activity, and smoking. The men were divided into four groups according to their self-estimated average sleep duration at the start of the study: five or fewer hours, six hours, seven to eight hours (considered normal sleep duration), and more than eight hours.

Participants were followed up for 21 years for the occurrence of major cardiovascular events, which included heart attack, stroke, hospitalization due to heart failure, coronary revascularization, or death from cardiovascular disease. Data on cardiovascular events were collected from medical records, the Swedish Hospital Discharge Registry, and the Swedish Cause of Death Register.

Men with incomplete data on sleep duration, incomplete follow-up information, or who had a major cardiovascular event before the start of the study were excluded, leaving a total of 759 men for the analyses.

High blood pressure, diabetes, obesity, current smoking, low physical activity, and poor sleep quality were more common in men who slept for five or fewer hours per night, compared with those who slept for seven to eight hours.

Compared with those with normal sleep duration, men who slept for five or fewer hours per night had a twofold higher risk of having a major cardiovascular event by age 71. The risk remained doubled after adjusting for cardiovascular risk factors at the start of the study, including obesity, diabetes, and smoking.

“Men with the shortest sleep duration at the age of 50 were twice as likely to have had a cardiovascular event by age 71 as those who slept a normal amount, even when other risk factors were taken into account,” said Ms. Bengtsson.

“In our study, the magnitude of increased cardiovascular risk associated with insufficient sleep is similar to that of smoking or having diabetes at age 50. This was an observational study, so, based on our findings, we cannot conclude that short sleep causes cardiovascular disease or say definitively that sleeping more will reduce risk. However, the findings do suggest that sleep is important, and that should be a wake-up call to all of us.”

How Long Is a Good Night’s Sleep?

Researchers have found that a sweet spot of six to eight hours’ sleep per night is most beneficial for heart health. More or less sleep is detrimental.

“We spend one-third of our lives sleeping, yet we know little about the impact of this biologic need on the cardiovascular system,” said Epameinondas Fountas, MD, of the Onassis Cardiac Surgery Centre in Athens.

The study investigated the relationship between sleep duration and cardiovascular disease using a meta-analysis that included 11 prospective studies published within the past five years of more than one million adults without cardiovascular disease.

Two groups, one with short (ie, fewer than six hours) and another with long (ie, more than eight hours) nightly sleep duration, were compared with the reference group (ie, six to eight hours’ sleep).

Short and long sleepers had a greater risk of developing or dying from coronary artery disease or stroke. Compared with adults who slept for six to eight hours per night, short and long sleepers had 11% and 33% greater risks, respectively, of developing or dying from coronary artery disease or stroke during an average follow-up of 9.3 years.

“Our findings suggest that too much or too little sleep may be bad for the heart,” said Dr. Fountas. “More research is needed to clarify exactly why, but we do know that sleep influences biologic processes like glucose metabolism, blood pressure, and inflammation, all of which have an impact on cardiovascular disease.”

A strength of the current analysis is that only prospective studies were included, noted Dr. Fountas. This technique avoids recall bias.

“Having the odd short night or lie-in is unlikely to be detrimental to health, but evidence is accumulating that prolonged nightly sleep deprivation or excessive sleeping should be avoided,” said Dr. Fountas. “The good news is that there are plenty of ways to get into the habit of getting six to eight hours a night: for example, by going to bed and getting up at the same time every day, avoiding alcohol and caffeine before bed, eating healthily, and being physically active. Getting the right amount of sleep is an important part of a healthy lifestyle.”

Four in 10 Patients With Atrial Fibrillation Have Unrecognized Brain Damage

Four out of 10 patients with atrial fibrillation but no history of stroke or transient ischemic attack have previously unrecognized brain damage, according to the first results of the Swiss Atrial Fibrillation Cohort Study (Swiss-AF).

“Our results suggest that clinically unrecognized brain damage may explain the association between dementia and atrial fibrillation in patients without prior stroke,” said David Conen, MD, MPH, Associate Professor of Cardiology at McMaster University in Hamilton, Canada.

Patients with atrial fibrillation have a significantly increased risk of stroke, which is why most are treated with oral anticoagulation. This increased stroke risk is probably the main reason why patients with atrial fibrillation also face an increased risk of cognitive dysfunction and dementia. The relationship between atrial fibrillation and dementia has also been shown among patients without prior strokes, however, meaning that additional mechanisms must be involved. Clarifying the mechanisms by which atrial fibrillation increases the risk of cognitive dysfunction and dementia is a first step towards developing preventive measures.

Swiss-AF is a prospective, observational study designed to pinpoint the mechanisms of cognitive decline in patients with atrial fibrillation. Dr. Conen’s analysis investigated the prevalence of silent brain damage in patients with atrial fibrillation.

The study enrolled 2,415 patients older than 65 with atrial fibrillation between 2014 and 2017 from 14 centers in Switzerland. All patients without contraindications underwent standardized brain MRI, and the images were analyzed in a central core laboratory. Scans were available in 1,736 patients. Of those patients, 347 (20%) had a history of stroke or transient ischemic attack and were excluded from the analysis.

The final analysis included 1,389 patients with atrial fibrillation but no history of stroke or transient ischemic attack. The average age of participants was 72, and 26% were women. The scans showed that 569 (41%) patients had at least one type of previously unrecognized brain damage: 207 (15%) had a cerebral infarct, 269 (19%) had microbleeds, and 222 (16%) had lacunes.

“Four in 10 patients with atrial fibrillation but no history of stroke or transient ischemic attack had clinically unrecognized silent brain lesions,” said Dr. Conen. “This brain damage could trigger cognitive decline.”

Most study participants (1,234; 89%) were treated with oral anticoagulants. Stefan Osswald, MD, Chief of Cardiology at University Hospital Basel in Switzerland, noted that the cross-sectional analysis looked at the data at a single point in time and cannot address the question of whether the cerebral infarcts and other brain lesions occurred before or after initiation of oral anticoagulation. “The findings nevertheless raise the issue that oral anticoagulation might not prevent all brain damage in patients with atrial fibrillation,” he said.

“All Swiss-AF participants underwent extensive cognitive testing. These data will be analyzed to see whether patients with silent brain lesions also have impaired cognitive function,” said Dr. Conen. Collaborations with other study groups will help determine whether these findings are specific to patients with atrial fibrillation.

Impaired Mental Status Doubles Elderly’s Risk of Death After Heart Attack

Impaired mental status is associated with a doubled risk of death one year after a heart attack in elderly patients, according to researchers.

“Cardiologists should consider conducting simple tests to assess mental status in elderly people after a heart attack,” said Farzin Beygui, MD, hospital practitioner at Caen University Hospital in France. “Patients with reduced mental status can then receive more intensive management such as regular follow-up appointments with their general practitioners or nurses, more specific assessment for an early diagnosis of dementia, and tailored therapy.”

The risks of dementia, Alzheimer’s disease, confusion, and delirium increase with age. Elderly people are also at higher risk of having a heart attack and dying afterwards. People aged 75 and older account for approximately one-third of heart attack admissions and more than half of those dying in the hospital after admission for a heart attack. Until now, it was not known whether impaired mental status affected the prognosis of elderly patients with heart attack.

This study assessed the impact of mental status on the risk of death in 600 patients age 75 and above consecutively admitted for heart attack and followed up for at least one year. Mental status was assessed using the Mini-Mental State Examination (MMSE) and the Confusion Assessment Method (CAM).Cognitive impairment was detected in 174 (29%) patients. Patients with impaired mental function were more than twice as likely to be dead one year after their heart attack than those with healthy mental function. The association was independent of other potential predictors of death such as age, sex, invasive treatment, type of myocardial infarction, heart failure, and severity of the heart attack.

Impaired mental status was also associated with a nearly fourfold higher rate of bleeding complications while in the hospital and a more than twofold higher risk of being readmitted to the hospital for cardiovascular causes within three months after discharge.

“Almost one-third of elderly heart attack patients in our study had reduced mental capacity,” said Dr. Beygui. “These patients had higher risks of bleeding, rehospitalization, and death. This may be because they forget to take their medicines or take them more than prescribed, rather than because of poor cognitive function itself.

“Assessing mental status is a simple way to identify elderly patients at particularly high risk of poor outcomes following a heart attack. Identifying these patients may help us target treatment to those who need it most.”

Patients With High Blood Pressure Should Undergo Clock Drawing Test

A clock drawing test for detecting cognitive dysfunction should be conducted routinely in patients with high blood pressure, according to researchers.

Patients with high blood pressure who have impaired cognitive function are at increased risk of developing dementia within five years. Despite this known link, cognitive function is not routinely measured in patients with high blood pressure.

“The ability to draw the numbers of a clock and a particular time is an easy way to find out if a patient with high blood pressure has cognitive impairment,” said Augusto Vicario, MD, a cardiologist at the Cardiovascular Institute of Buenos Aires. “Identifying these patients provides the opportunity to intervene before dementia develops.”

The Heart-Brain Study in Argentina evaluated the usefulness of the clock drawing test, compared with the Mini-Mental State Examination (MMSE), to detect cognitive impairment in 1,414 adults with high blood pressure recruited from 18 cardiology centers in Argentina. The population’s average blood pressure was 144/84 mm Hg, average age was 60, and 62% were women.

For the clock drawing test, patients were given a piece of paper with a circle on it (diameter, 10 cm). They were asked to write the numbers of the clock in the correct positions inside the circle and draw hands on the clock indicating the time “20 to four.” Patients were scored as having normal cognition or moderate or severe cognitive impairment.

The researchers found a higher prevalence of cognitive impairment with the clock drawing test (36%), compared with the MMSE (21%). Three of 10 patients who had a normal MMSE score had an abnormal clock drawing result. The disparity in results between the two tests was greatest in middle-aged patients.

“Untreated high blood pressure silently and progressively damages the arteries in the subcortex of the brain and stops communication between the subcortex and frontal lobe,” said Dr. Vicario. “This disconnect leads to impaired executive functions such as planning, visuospatial abilities, remembering details, and decision-making. The clock drawing test is known to evaluate executive functions. The MMSE evaluates several other cognitive abilities but is weakly correlated with executive functions.

“Our study suggests that the clock drawing test should be preferred over the MMSE for early detection of executive dysfunction in patients with high blood pressure, particularly in middle age. We think the score on the clock drawing test can be considered a surrogate measure of silent vascular damage in the brain and identifies patients at greater risk of developing dementia. In our study, more than one-third of patients were at risk.

“The clock drawing test should be adopted as a routine screening tool for cognitive decline in patients with high blood pressure. Further studies are needed to determine whether lowering blood pressure can prevent progression to dementia,” Dr. Vicario concluded.

Short Sleep Associated With Doubled Risk of Cardiovascular Disease

Middle-aged men who sleep for five hours or fewer per night have twice the risk of developing a major cardiovascular event during the following two decades, compared with men who sleep for seven to eight hours, according to a study.

“For people with busy lives, sleeping may feel like a waste of time, but our study suggests that short sleep could be linked with future cardiovascular disease,” said Moa Bengtsson of the University of Gothenburg, Sweden.

Previous studies have generated conflicting evidence on whether short sleep is associated with a greater chance of having a future cardiovascular event. This study investigated this relationship in 50-year-old men.

In 1993, 50% of all men born in 1943 and living in Gothenburg were randomly selected to participate in the study. Of the 1,463 invited, 798 (55%) men agreed to take part. Participants underwent a physical examination and completed a questionnaire on current health conditions, average sleep duration, physical activity, and smoking. The men were divided into four groups according to their self-estimated average sleep duration at the start of the study: five or fewer hours, six hours, seven to eight hours (considered normal sleep duration), and more than eight hours.

Participants were followed up for 21 years for the occurrence of major cardiovascular events, which included heart attack, stroke, hospitalization due to heart failure, coronary revascularization, or death from cardiovascular disease. Data on cardiovascular events were collected from medical records, the Swedish Hospital Discharge Registry, and the Swedish Cause of Death Register.

Men with incomplete data on sleep duration, incomplete follow-up information, or who had a major cardiovascular event before the start of the study were excluded, leaving a total of 759 men for the analyses.

High blood pressure, diabetes, obesity, current smoking, low physical activity, and poor sleep quality were more common in men who slept for five or fewer hours per night, compared with those who slept for seven to eight hours.

Compared with those with normal sleep duration, men who slept for five or fewer hours per night had a twofold higher risk of having a major cardiovascular event by age 71. The risk remained doubled after adjusting for cardiovascular risk factors at the start of the study, including obesity, diabetes, and smoking.

“Men with the shortest sleep duration at the age of 50 were twice as likely to have had a cardiovascular event by age 71 as those who slept a normal amount, even when other risk factors were taken into account,” said Ms. Bengtsson.

“In our study, the magnitude of increased cardiovascular risk associated with insufficient sleep is similar to that of smoking or having diabetes at age 50. This was an observational study, so, based on our findings, we cannot conclude that short sleep causes cardiovascular disease or say definitively that sleeping more will reduce risk. However, the findings do suggest that sleep is important, and that should be a wake-up call to all of us.”

How Long Is a Good Night’s Sleep?

Researchers have found that a sweet spot of six to eight hours’ sleep per night is most beneficial for heart health. More or less sleep is detrimental.

“We spend one-third of our lives sleeping, yet we know little about the impact of this biologic need on the cardiovascular system,” said Epameinondas Fountas, MD, of the Onassis Cardiac Surgery Centre in Athens.

The study investigated the relationship between sleep duration and cardiovascular disease using a meta-analysis that included 11 prospective studies published within the past five years of more than one million adults without cardiovascular disease.

Two groups, one with short (ie, fewer than six hours) and another with long (ie, more than eight hours) nightly sleep duration, were compared with the reference group (ie, six to eight hours’ sleep).

Short and long sleepers had a greater risk of developing or dying from coronary artery disease or stroke. Compared with adults who slept for six to eight hours per night, short and long sleepers had 11% and 33% greater risks, respectively, of developing or dying from coronary artery disease or stroke during an average follow-up of 9.3 years.

“Our findings suggest that too much or too little sleep may be bad for the heart,” said Dr. Fountas. “More research is needed to clarify exactly why, but we do know that sleep influences biologic processes like glucose metabolism, blood pressure, and inflammation, all of which have an impact on cardiovascular disease.”

A strength of the current analysis is that only prospective studies were included, noted Dr. Fountas. This technique avoids recall bias.

“Having the odd short night or lie-in is unlikely to be detrimental to health, but evidence is accumulating that prolonged nightly sleep deprivation or excessive sleeping should be avoided,” said Dr. Fountas. “The good news is that there are plenty of ways to get into the habit of getting six to eight hours a night: for example, by going to bed and getting up at the same time every day, avoiding alcohol and caffeine before bed, eating healthily, and being physically active. Getting the right amount of sleep is an important part of a healthy lifestyle.”

Four in 10 Patients With Atrial Fibrillation Have Unrecognized Brain Damage

Four out of 10 patients with atrial fibrillation but no history of stroke or transient ischemic attack have previously unrecognized brain damage, according to the first results of the Swiss Atrial Fibrillation Cohort Study (Swiss-AF).

“Our results suggest that clinically unrecognized brain damage may explain the association between dementia and atrial fibrillation in patients without prior stroke,” said David Conen, MD, MPH, Associate Professor of Cardiology at McMaster University in Hamilton, Canada.

Patients with atrial fibrillation have a significantly increased risk of stroke, which is why most are treated with oral anticoagulation. This increased stroke risk is probably the main reason why patients with atrial fibrillation also face an increased risk of cognitive dysfunction and dementia. The relationship between atrial fibrillation and dementia has also been shown among patients without prior strokes, however, meaning that additional mechanisms must be involved. Clarifying the mechanisms by which atrial fibrillation increases the risk of cognitive dysfunction and dementia is a first step towards developing preventive measures.

Swiss-AF is a prospective, observational study designed to pinpoint the mechanisms of cognitive decline in patients with atrial fibrillation. Dr. Conen’s analysis investigated the prevalence of silent brain damage in patients with atrial fibrillation.

The study enrolled 2,415 patients older than 65 with atrial fibrillation between 2014 and 2017 from 14 centers in Switzerland. All patients without contraindications underwent standardized brain MRI, and the images were analyzed in a central core laboratory. Scans were available in 1,736 patients. Of those patients, 347 (20%) had a history of stroke or transient ischemic attack and were excluded from the analysis.

The final analysis included 1,389 patients with atrial fibrillation but no history of stroke or transient ischemic attack. The average age of participants was 72, and 26% were women. The scans showed that 569 (41%) patients had at least one type of previously unrecognized brain damage: 207 (15%) had a cerebral infarct, 269 (19%) had microbleeds, and 222 (16%) had lacunes.

“Four in 10 patients with atrial fibrillation but no history of stroke or transient ischemic attack had clinically unrecognized silent brain lesions,” said Dr. Conen. “This brain damage could trigger cognitive decline.”

Most study participants (1,234; 89%) were treated with oral anticoagulants. Stefan Osswald, MD, Chief of Cardiology at University Hospital Basel in Switzerland, noted that the cross-sectional analysis looked at the data at a single point in time and cannot address the question of whether the cerebral infarcts and other brain lesions occurred before or after initiation of oral anticoagulation. “The findings nevertheless raise the issue that oral anticoagulation might not prevent all brain damage in patients with atrial fibrillation,” he said.

“All Swiss-AF participants underwent extensive cognitive testing. These data will be analyzed to see whether patients with silent brain lesions also have impaired cognitive function,” said Dr. Conen. Collaborations with other study groups will help determine whether these findings are specific to patients with atrial fibrillation.

Impaired Mental Status Doubles Elderly’s Risk of Death After Heart Attack

Impaired mental status is associated with a doubled risk of death one year after a heart attack in elderly patients, according to researchers.

“Cardiologists should consider conducting simple tests to assess mental status in elderly people after a heart attack,” said Farzin Beygui, MD, hospital practitioner at Caen University Hospital in France. “Patients with reduced mental status can then receive more intensive management such as regular follow-up appointments with their general practitioners or nurses, more specific assessment for an early diagnosis of dementia, and tailored therapy.”

The risks of dementia, Alzheimer’s disease, confusion, and delirium increase with age. Elderly people are also at higher risk of having a heart attack and dying afterwards. People aged 75 and older account for approximately one-third of heart attack admissions and more than half of those dying in the hospital after admission for a heart attack. Until now, it was not known whether impaired mental status affected the prognosis of elderly patients with heart attack.

This study assessed the impact of mental status on the risk of death in 600 patients age 75 and above consecutively admitted for heart attack and followed up for at least one year. Mental status was assessed using the Mini-Mental State Examination (MMSE) and the Confusion Assessment Method (CAM).Cognitive impairment was detected in 174 (29%) patients. Patients with impaired mental function were more than twice as likely to be dead one year after their heart attack than those with healthy mental function. The association was independent of other potential predictors of death such as age, sex, invasive treatment, type of myocardial infarction, heart failure, and severity of the heart attack.

Impaired mental status was also associated with a nearly fourfold higher rate of bleeding complications while in the hospital and a more than twofold higher risk of being readmitted to the hospital for cardiovascular causes within three months after discharge.

“Almost one-third of elderly heart attack patients in our study had reduced mental capacity,” said Dr. Beygui. “These patients had higher risks of bleeding, rehospitalization, and death. This may be because they forget to take their medicines or take them more than prescribed, rather than because of poor cognitive function itself.

“Assessing mental status is a simple way to identify elderly patients at particularly high risk of poor outcomes following a heart attack. Identifying these patients may help us target treatment to those who need it most.”

BALTIMORE—Lemborexant, an investigational treatment for insomnia, does not impair postural stability or driving ability on the morning after dosing, according to the results of phase I studies presented at the 32nd Annual Meeting of the Associated Professional Sleep Societies. In addition, lemborexant does not impair the ability to be awakened at night and helps patients return to sleep faster than placebo. Lemborexant is a dual orexin receptor antagonist in development for the treatment of insomnia and irregular sleep–wake rhythm disorder.

Comparing Lemborexant With Zolpidem

In one double-blind study, Patricia Murphy, PhD, Director of Clinical Research at Eisai, and colleagues randomized 63 healthy volunteers to one of four treatment sequences. The treatments were 5 mg of lemborexant, 10 mg of lemborexant, 6.25 mg of zolpidem, and placebo. Treatments were administered five minutes before bedtime.

At about four hours after bedtime, participants were exposed through earbuds to a 15-dB tone that became 5 dB louder every 15 seconds. Investigators recorded the volume required to awaken the participants. Within five minutes of awakening, participants had their postural stability measured by ataxiameter. After this assessment, the investigators used polysomnography to measure the time it took for participants to fall asleep again. Finally, participants underwent a second postural stability measurement after awakening in the morning. Participants entered a washout period of at least 14 days after each treatment and repeated the same tests for each treatment.

Approximately 78% of the population was female, and the average age was 63.6. Neither lemborexant nor zolpidem significantly increased participants’ auditory awakening threshold (AAT), compared with placebo. The mean AAT was 50 dB for placebo, 51.8 dB for 5 mg of lemborexant, 51.7 dB for 10 mg of lemborexant, and 58.4 dB for zolpidem.

The 5-mg dose of lemborexant did not significantly decrease postural stability, compared with placebo, when participants were awakened at night. The 10-mg dose of lemborexant caused a clinically meaningful decrease in postural stability, and zolpidem was associated with a decrease in stability that was twice that seen with 10 mg of lemborexant.

The mean latency to return to sleep was 40.9 minutes for placebo, 18.1 minutes for 5 mg of lemborexant, 12.1 minutes for 10 mg of lemborexant, and 19.6 minutes for zolpidem. Neither dose of lemborexant significantly affected postural stability after eight hours of sleep. Zolpidem was associated with a significant decrease in postural stability, compared with placebo, but the increase was not clinically meaningful.

Comparing Lemborexant With Zopiclone

In a separate study, Annemiek Vermeeren, PhD, Assistant Pro­fessor of Neuropsychology and Psycho­pharmacology at Maastricht Uni­versity in the Netherlands, and colleagues evaluated whether lemborexant affected driving performance on the morning after dosing. They enrolled 48 healthy adults into the double-blind, incomplete crossover trial. Participants were randomized to one of 12 treatment sequences, and treatments included lemborexant (2.5 mg, 5 mg, or 10 mg) for eight consecutive days, zopiclone (7.5 mg) on Days 1 and 8 (with placebo on intervening days), and placebo for eight consecutive days. A washout period of at least 14 days followed each eight-day treatment period. Each participant received two of the three lemborexant doses.

Participants completed a practice driving test during screening, and driving performance was assessed at approximately nine hours after dosing on Days 2 and 9. Subjects were instructed to drive at 95 km/h within one lane for approximately one hour, while instruments on the vehicle measured their standard deviation of lateral position (SDLP).

The population’s mean age was 58.5, and 54.2% of participants were male. The mean increases from placebo in SDLP were less than 0.75 cm on both test days after all doses of lemborexant. These changes were neither statistically significant nor clinically meaningful. Zopiclone was associated with increases in SDLP of 2.04 cm on Day 2 and 1.88 cm on Day 9. These changes were statistically significant and clinically meaningful on both days.

The investigators categorized patients as between ages 21 and 65 or age 65 or older. The effects of lemborexant did not differ between adults older and younger than 65 or between males and females.

The driving instructor terminated three of 384 driving tests early. All participants whose tests were terminated had taken zopiclone.

The investigators did not observe any serious adverse events, severe treatment-emergent adverse events, or treatment-emergent adverse events leading to study discontinuation. The most common treatment-emergent adverse events reported after treatment with lemborexant were somnolence, headache, and dry mouth. The most common treatment-emergent adverse events reported after treatment with zopiclone were somnolence, dysgeusia, and dizziness.

Eisai and Purdue Pharma, the developers of lemborexant, funded the studies.

—Erik Greb

Suggested Reading

Murphy P, Moline M, Mayleben D, et al. Lemborexant, A dual orexin receptor antagonist (DORA) for the treatment of insomnia disorder: results from a Bayesian, adaptive, randomized, double-blind, placebo-controlled study. J Clin Sleep Med. 2017;13(11):1289-1299.

BALTIMORE—Lemborexant, an investigational treatment for insomnia, does not impair postural stability or driving ability on the morning after dosing, according to the results of phase I studies presented at the 32nd Annual Meeting of the Associated Professional Sleep Societies. In addition, lemborexant does not impair the ability to be awakened at night and helps patients return to sleep faster than placebo. Lemborexant is a dual orexin receptor antagonist in development for the treatment of insomnia and irregular sleep–wake rhythm disorder.

Comparing Lemborexant With Zolpidem

In one double-blind study, Patricia Murphy, PhD, Director of Clinical Research at Eisai, and colleagues randomized 63 healthy volunteers to one of four treatment sequences. The treatments were 5 mg of lemborexant, 10 mg of lemborexant, 6.25 mg of zolpidem, and placebo. Treatments were administered five minutes before bedtime.

At about four hours after bedtime, participants were exposed through earbuds to a 15-dB tone that became 5 dB louder every 15 seconds. Investigators recorded the volume required to awaken the participants. Within five minutes of awakening, participants had their postural stability measured by ataxiameter. After this assessment, the investigators used polysomnography to measure the time it took for participants to fall asleep again. Finally, participants underwent a second postural stability measurement after awakening in the morning. Participants entered a washout period of at least 14 days after each treatment and repeated the same tests for each treatment.

Approximately 78% of the population was female, and the average age was 63.6. Neither lemborexant nor zolpidem significantly increased participants’ auditory awakening threshold (AAT), compared with placebo. The mean AAT was 50 dB for placebo, 51.8 dB for 5 mg of lemborexant, 51.7 dB for 10 mg of lemborexant, and 58.4 dB for zolpidem.

The 5-mg dose of lemborexant did not significantly decrease postural stability, compared with placebo, when participants were awakened at night. The 10-mg dose of lemborexant caused a clinically meaningful decrease in postural stability, and zolpidem was associated with a decrease in stability that was twice that seen with 10 mg of lemborexant.

The mean latency to return to sleep was 40.9 minutes for placebo, 18.1 minutes for 5 mg of lemborexant, 12.1 minutes for 10 mg of lemborexant, and 19.6 minutes for zolpidem. Neither dose of lemborexant significantly affected postural stability after eight hours of sleep. Zolpidem was associated with a significant decrease in postural stability, compared with placebo, but the increase was not clinically meaningful.

Comparing Lemborexant With Zopiclone

In a separate study, Annemiek Vermeeren, PhD, Assistant Pro­fessor of Neuropsychology and Psycho­pharmacology at Maastricht Uni­versity in the Netherlands, and colleagues evaluated whether lemborexant affected driving performance on the morning after dosing. They enrolled 48 healthy adults into the double-blind, incomplete crossover trial. Participants were randomized to one of 12 treatment sequences, and treatments included lemborexant (2.5 mg, 5 mg, or 10 mg) for eight consecutive days, zopiclone (7.5 mg) on Days 1 and 8 (with placebo on intervening days), and placebo for eight consecutive days. A washout period of at least 14 days followed each eight-day treatment period. Each participant received two of the three lemborexant doses.

Participants completed a practice driving test during screening, and driving performance was assessed at approximately nine hours after dosing on Days 2 and 9. Subjects were instructed to drive at 95 km/h within one lane for approximately one hour, while instruments on the vehicle measured their standard deviation of lateral position (SDLP).

The population’s mean age was 58.5, and 54.2% of participants were male. The mean increases from placebo in SDLP were less than 0.75 cm on both test days after all doses of lemborexant. These changes were neither statistically significant nor clinically meaningful. Zopiclone was associated with increases in SDLP of 2.04 cm on Day 2 and 1.88 cm on Day 9. These changes were statistically significant and clinically meaningful on both days.

The investigators categorized patients as between ages 21 and 65 or age 65 or older. The effects of lemborexant did not differ between adults older and younger than 65 or between males and females.

The driving instructor terminated three of 384 driving tests early. All participants whose tests were terminated had taken zopiclone.

The investigators did not observe any serious adverse events, severe treatment-emergent adverse events, or treatment-emergent adverse events leading to study discontinuation. The most common treatment-emergent adverse events reported after treatment with lemborexant were somnolence, headache, and dry mouth. The most common treatment-emergent adverse events reported after treatment with zopiclone were somnolence, dysgeusia, and dizziness.

Eisai and Purdue Pharma, the developers of lemborexant, funded the studies.

—Erik Greb

Suggested Reading

Murphy P, Moline M, Mayleben D, et al. Lemborexant, A dual orexin receptor antagonist (DORA) for the treatment of insomnia disorder: results from a Bayesian, adaptive, randomized, double-blind, placebo-controlled study. J Clin Sleep Med. 2017;13(11):1289-1299.

BALTIMORE—Lemborexant, an investigational treatment for insomnia, does not impair postural stability or driving ability on the morning after dosing, according to the results of phase I studies presented at the 32nd Annual Meeting of the Associated Professional Sleep Societies. In addition, lemborexant does not impair the ability to be awakened at night and helps patients return to sleep faster than placebo. Lemborexant is a dual orexin receptor antagonist in development for the treatment of insomnia and irregular sleep–wake rhythm disorder.

Comparing Lemborexant With Zolpidem

In one double-blind study, Patricia Murphy, PhD, Director of Clinical Research at Eisai, and colleagues randomized 63 healthy volunteers to one of four treatment sequences. The treatments were 5 mg of lemborexant, 10 mg of lemborexant, 6.25 mg of zolpidem, and placebo. Treatments were administered five minutes before bedtime.

At about four hours after bedtime, participants were exposed through earbuds to a 15-dB tone that became 5 dB louder every 15 seconds. Investigators recorded the volume required to awaken the participants. Within five minutes of awakening, participants had their postural stability measured by ataxiameter. After this assessment, the investigators used polysomnography to measure the time it took for participants to fall asleep again. Finally, participants underwent a second postural stability measurement after awakening in the morning. Participants entered a washout period of at least 14 days after each treatment and repeated the same tests for each treatment.

Approximately 78% of the population was female, and the average age was 63.6. Neither lemborexant nor zolpidem significantly increased participants’ auditory awakening threshold (AAT), compared with placebo. The mean AAT was 50 dB for placebo, 51.8 dB for 5 mg of lemborexant, 51.7 dB for 10 mg of lemborexant, and 58.4 dB for zolpidem.

The 5-mg dose of lemborexant did not significantly decrease postural stability, compared with placebo, when participants were awakened at night. The 10-mg dose of lemborexant caused a clinically meaningful decrease in postural stability, and zolpidem was associated with a decrease in stability that was twice that seen with 10 mg of lemborexant.

The mean latency to return to sleep was 40.9 minutes for placebo, 18.1 minutes for 5 mg of lemborexant, 12.1 minutes for 10 mg of lemborexant, and 19.6 minutes for zolpidem. Neither dose of lemborexant significantly affected postural stability after eight hours of sleep. Zolpidem was associated with a significant decrease in postural stability, compared with placebo, but the increase was not clinically meaningful.

Comparing Lemborexant With Zopiclone

In a separate study, Annemiek Vermeeren, PhD, Assistant Pro­fessor of Neuropsychology and Psycho­pharmacology at Maastricht Uni­versity in the Netherlands, and colleagues evaluated whether lemborexant affected driving performance on the morning after dosing. They enrolled 48 healthy adults into the double-blind, incomplete crossover trial. Participants were randomized to one of 12 treatment sequences, and treatments included lemborexant (2.5 mg, 5 mg, or 10 mg) for eight consecutive days, zopiclone (7.5 mg) on Days 1 and 8 (with placebo on intervening days), and placebo for eight consecutive days. A washout period of at least 14 days followed each eight-day treatment period. Each participant received two of the three lemborexant doses.

Participants completed a practice driving test during screening, and driving performance was assessed at approximately nine hours after dosing on Days 2 and 9. Subjects were instructed to drive at 95 km/h within one lane for approximately one hour, while instruments on the vehicle measured their standard deviation of lateral position (SDLP).

The population’s mean age was 58.5, and 54.2% of participants were male. The mean increases from placebo in SDLP were less than 0.75 cm on both test days after all doses of lemborexant. These changes were neither statistically significant nor clinically meaningful. Zopiclone was associated with increases in SDLP of 2.04 cm on Day 2 and 1.88 cm on Day 9. These changes were statistically significant and clinically meaningful on both days.

The investigators categorized patients as between ages 21 and 65 or age 65 or older. The effects of lemborexant did not differ between adults older and younger than 65 or between males and females.

The driving instructor terminated three of 384 driving tests early. All participants whose tests were terminated had taken zopiclone.

The investigators did not observe any serious adverse events, severe treatment-emergent adverse events, or treatment-emergent adverse events leading to study discontinuation. The most common treatment-emergent adverse events reported after treatment with lemborexant were somnolence, headache, and dry mouth. The most common treatment-emergent adverse events reported after treatment with zopiclone were somnolence, dysgeusia, and dizziness.

Eisai and Purdue Pharma, the developers of lemborexant, funded the studies.

—Erik Greb

Suggested Reading

Murphy P, Moline M, Mayleben D, et al. Lemborexant, A dual orexin receptor antagonist (DORA) for the treatment of insomnia disorder: results from a Bayesian, adaptive, randomized, double-blind, placebo-controlled study. J Clin Sleep Med. 2017;13(11):1289-1299.

BALTIMORE—Objective and subjective sleep measures are associated with fatigue in people with multiple sclerosis (MS), according to a meta-analysis presented at the 32nd Annual Meeting of the Associated Professional Sleep Societies.

Evidence suggests that individuals with MS have disruptions in sleep that are associated with and may contribute to fatigue, said Jagriti “Jackie” Bhattarai, PhD, a postdoctoral fellow in the MS Rehabilitation Research Laboratory at the Johns Hopkins School of Medicine’s Department of Physical Medicine and Rehabilitation in Baltimore. Among the sleep parameters investigated, sleep staging, sleep-related movement, and subjective insomnia had moderate associations with fatigue. Other sleep parameters examined in the study were not statistically significantly associated with fatigue, she said.

A Major Factor in Disability

Fatigue is a leading contributor to disability in patients with MS. Although fatigue is a complex symptom with multiple neurologic and behavioral causes, emerging evidence suggests that “sleep disturbance may have a significant role in the development or maintenance of fatigue in MS,” Dr. Bhattarai said. The relationship between sleep parameters and fatigue in people with MS is not well understood, however, she said.

To examine the relationship between commonly used sleep parameters and fatigue in MS, Dr. Bhattarai and colleagues identified studies that included at least one validated measure of fatigue and one validated measure of sleep disturbance. They included studies that reported the effect sizes of the associations between sleep and fatigue or provided enough data for the investigators to compute the effect sizes.

Their meta-analysis included 37 studies with 6,129 participants. Participants had an average age of 42 and MS duration of 9.5 years. About 80% of the sample had relapsing-remitting MS.

Sleep measures included polysomnography, actigraphy, and the multiple sleep latency test, as well as subjective measures such as the Insomnia Severity Index, the Pittsburgh Sleep Quality Index, and the Medical Outcomes Study Sleep Scale.

Fatigue was measured using the Fatigue Severity Scale, the modified Fatigue Impact Scale, or the Neurological Fatigue Index for MS.

Effect sizes varied across studies, as did the parameters examined within each study. The mean effect size was the largest for the association between REM sleep onset latency (ie, the time between sleep onset and initiation of REM sleep) and fatigue (r = 0.42), though this effect size was based on only two studies, and the association requires further investigation. “Shorter REM sleep onset latency has been associated with depression and narcolepsy,” both of which are more common in people with MS than in the general population, Dr. Bhattarai said. Subjective insomnia (r = 0.36) and objective sleep-related movement (r = 0.34) also yielded moderate effect sizes. “The shorter the REM sleep onset latency and the more subjective complaints that individuals have about their sleep, the greater the level of fatigue people with MS reported,” she said. “The more sleep-related movement that people have, the greater their level of MS-related fatigue.”

Potential to Inform Treatment Approach

The association between fatigue and objective sleep-disordered breathing was not statistically significant. Subjective sleep-disordered breathing, objective nocturnal arousals, sleep efficiency, sleep onset latency, and sleep duration had weak effect sizes. These problems are common and require treatment, however, Dr. Bhattarai said.

“When treating patients with MS who are experiencing MS-related fatigue, interventions geared toward improving patients’ perceived sleep quality and addressing MS symptoms that might disrupt sleep (eg, nocturia and periodic leg movements) may offer an avenue for improving fatigue,” said Dr. Bhattarai. “However, these effects remain to be shown in a randomized controlled trial.”

—Jake Remaly

BALTIMORE—Objective and subjective sleep measures are associated with fatigue in people with multiple sclerosis (MS), according to a meta-analysis presented at the 32nd Annual Meeting of the Associated Professional Sleep Societies.

Evidence suggests that individuals with MS have disruptions in sleep that are associated with and may contribute to fatigue, said Jagriti “Jackie” Bhattarai, PhD, a postdoctoral fellow in the MS Rehabilitation Research Laboratory at the Johns Hopkins School of Medicine’s Department of Physical Medicine and Rehabilitation in Baltimore. Among the sleep parameters investigated, sleep staging, sleep-related movement, and subjective insomnia had moderate associations with fatigue. Other sleep parameters examined in the study were not statistically significantly associated with fatigue, she said.

A Major Factor in Disability

Fatigue is a leading contributor to disability in patients with MS. Although fatigue is a complex symptom with multiple neurologic and behavioral causes, emerging evidence suggests that “sleep disturbance may have a significant role in the development or maintenance of fatigue in MS,” Dr. Bhattarai said. The relationship between sleep parameters and fatigue in people with MS is not well understood, however, she said.

To examine the relationship between commonly used sleep parameters and fatigue in MS, Dr. Bhattarai and colleagues identified studies that included at least one validated measure of fatigue and one validated measure of sleep disturbance. They included studies that reported the effect sizes of the associations between sleep and fatigue or provided enough data for the investigators to compute the effect sizes.

Their meta-analysis included 37 studies with 6,129 participants. Participants had an average age of 42 and MS duration of 9.5 years. About 80% of the sample had relapsing-remitting MS.

Sleep measures included polysomnography, actigraphy, and the multiple sleep latency test, as well as subjective measures such as the Insomnia Severity Index, the Pittsburgh Sleep Quality Index, and the Medical Outcomes Study Sleep Scale.

Fatigue was measured using the Fatigue Severity Scale, the modified Fatigue Impact Scale, or the Neurological Fatigue Index for MS.

Effect sizes varied across studies, as did the parameters examined within each study. The mean effect size was the largest for the association between REM sleep onset latency (ie, the time between sleep onset and initiation of REM sleep) and fatigue (r = 0.42), though this effect size was based on only two studies, and the association requires further investigation. “Shorter REM sleep onset latency has been associated with depression and narcolepsy,” both of which are more common in people with MS than in the general population, Dr. Bhattarai said. Subjective insomnia (r = 0.36) and objective sleep-related movement (r = 0.34) also yielded moderate effect sizes. “The shorter the REM sleep onset latency and the more subjective complaints that individuals have about their sleep, the greater the level of fatigue people with MS reported,” she said. “The more sleep-related movement that people have, the greater their level of MS-related fatigue.”

Potential to Inform Treatment Approach

The association between fatigue and objective sleep-disordered breathing was not statistically significant. Subjective sleep-disordered breathing, objective nocturnal arousals, sleep efficiency, sleep onset latency, and sleep duration had weak effect sizes. These problems are common and require treatment, however, Dr. Bhattarai said.

“When treating patients with MS who are experiencing MS-related fatigue, interventions geared toward improving patients’ perceived sleep quality and addressing MS symptoms that might disrupt sleep (eg, nocturia and periodic leg movements) may offer an avenue for improving fatigue,” said Dr. Bhattarai. “However, these effects remain to be shown in a randomized controlled trial.”

—Jake Remaly

BALTIMORE—Objective and subjective sleep measures are associated with fatigue in people with multiple sclerosis (MS), according to a meta-analysis presented at the 32nd Annual Meeting of the Associated Professional Sleep Societies.

Evidence suggests that individuals with MS have disruptions in sleep that are associated with and may contribute to fatigue, said Jagriti “Jackie” Bhattarai, PhD, a postdoctoral fellow in the MS Rehabilitation Research Laboratory at the Johns Hopkins School of Medicine’s Department of Physical Medicine and Rehabilitation in Baltimore. Among the sleep parameters investigated, sleep staging, sleep-related movement, and subjective insomnia had moderate associations with fatigue. Other sleep parameters examined in the study were not statistically significantly associated with fatigue, she said.

A Major Factor in Disability

Fatigue is a leading contributor to disability in patients with MS. Although fatigue is a complex symptom with multiple neurologic and behavioral causes, emerging evidence suggests that “sleep disturbance may have a significant role in the development or maintenance of fatigue in MS,” Dr. Bhattarai said. The relationship between sleep parameters and fatigue in people with MS is not well understood, however, she said.

To examine the relationship between commonly used sleep parameters and fatigue in MS, Dr. Bhattarai and colleagues identified studies that included at least one validated measure of fatigue and one validated measure of sleep disturbance. They included studies that reported the effect sizes of the associations between sleep and fatigue or provided enough data for the investigators to compute the effect sizes.

Their meta-analysis included 37 studies with 6,129 participants. Participants had an average age of 42 and MS duration of 9.5 years. About 80% of the sample had relapsing-remitting MS.

Sleep measures included polysomnography, actigraphy, and the multiple sleep latency test, as well as subjective measures such as the Insomnia Severity Index, the Pittsburgh Sleep Quality Index, and the Medical Outcomes Study Sleep Scale.

Fatigue was measured using the Fatigue Severity Scale, the modified Fatigue Impact Scale, or the Neurological Fatigue Index for MS.

Effect sizes varied across studies, as did the parameters examined within each study. The mean effect size was the largest for the association between REM sleep onset latency (ie, the time between sleep onset and initiation of REM sleep) and fatigue (r = 0.42), though this effect size was based on only two studies, and the association requires further investigation. “Shorter REM sleep onset latency has been associated with depression and narcolepsy,” both of which are more common in people with MS than in the general population, Dr. Bhattarai said. Subjective insomnia (r = 0.36) and objective sleep-related movement (r = 0.34) also yielded moderate effect sizes. “The shorter the REM sleep onset latency and the more subjective complaints that individuals have about their sleep, the greater the level of fatigue people with MS reported,” she said. “The more sleep-related movement that people have, the greater their level of MS-related fatigue.”

Potential to Inform Treatment Approach

The association between fatigue and objective sleep-disordered breathing was not statistically significant. Subjective sleep-disordered breathing, objective nocturnal arousals, sleep efficiency, sleep onset latency, and sleep duration had weak effect sizes. These problems are common and require treatment, however, Dr. Bhattarai said.

“When treating patients with MS who are experiencing MS-related fatigue, interventions geared toward improving patients’ perceived sleep quality and addressing MS symptoms that might disrupt sleep (eg, nocturia and periodic leg movements) may offer an avenue for improving fatigue,” said Dr. Bhattarai. “However, these effects remain to be shown in a randomized controlled trial.”

—Jake Remaly

BALTIMORE—Patients with stroke and obstructive sleep apnea (OSA) are more likely than patients without these conditions to have atrial fibrillation, said Melissa Lipford, MD, a neurologist and sleep specialist at Mayo Clinic in Rochester, Minnesota. If physicians detect atrial fibrillation in this patient population, the finding may lead to more effective preventive stroke treatment, Dr. Lipford said at the 32nd Annual Meeting of the Associated Professional Sleep Societies.

“In patients who present with cryptogenic stroke, if they have a known history of moderate to severe OSA, perhaps these are candidates where we would give higher consideration to doing long-term monitoring to screen for occult arrhythmia. If we find it and put them on anticoagulation therapy, they will be at a 40% to 70% reduced risk of having a stroke, compared with only 20% if we maintain antiplatelet therapy.”

Physicians must confirm that a patient has atrial fibrillation before starting anticoagulation therapy, however, she said. “We cannot just start them on warfarin because of the risk of bleeding. If you have patients on aspirin therapy, their risk of a major bleed is probably only 0.5% per year. The risk is doubled with warfarin in the lowest-risk patients. But if you tack on age, hypertension, and other risk factors, that goes up to almost a 12% per year risk with warfarin,” she said. “In every patient you have to do a risk–benefit analysis…. If you document atrial fibrillation, that risk of having a stroke is so high that the risk of a stroke outweighs the risks of anticoagulation in most cases.”

Potential Mechanisms

Dr. Lipford described a 65-year-old man with cryptogenic stroke who was found to have severe OSA. Although 24-hour telemetry monitoring showed no evidence of arrhythmia, he could be a candidate for 30-day noninvasive ambulatory heart monitoring, Dr. Lipford said.

“Typically, in these patients, we put them on aspirin and generally control their risk factors,” she said. “Knowing that this patient has severe OSA … we might consider more strongly long-term cardiac monitoring to help screen for occult atrial arrhythmia.”

Atrial fibrillation affects as many as six million people in the United States, including 9% of patients over age 65. It increases a person’s risk of stroke fivefold, Dr. Lipford said.

“Unfortunately, atrial fibrillation is commonly undetected,” she said. Many patients do not have symptoms. Patients may have paroxysmal disease. Some patients only have episodes at night.

Cardiogenic embolism accounts for between 20% and 30% of ischemic strokes each year. Most of these strokes are due to atrial fibrillation, Dr. Lipford said. About 60% of these strokes are severely disabling, and 20% result in death.

Gami and colleagues examined the prevalence of OSA in patients with and without atrial fibrillation. Patients with atrial fibrillation were more likely to have OSA, compared with patients without atrial fibrillation (49% vs 32%). Mansukhani et al found that in patients with OSA and a history of stroke, about 50% had a history of atrial fibrillation or atrial flutter, compared with 10.8% of patients with OSA and no history of stroke.

Data from the Sleep Heart Health Study indicate that patients with severe OSA have an increased risk of atrial fibrillation, compared with patients without sleep-disordered breathing (4.8% vs 0.9%).

After procedures such as cardioversion, patients with untreated OSA are more likely reconvert to atrial fibrillation, Dr. Lipford said. Kanagala and colleagues found that 82% of patients with untreated OSA had recurrence of atrial fibrillation at 12 months after cardioversion, compared with 42% of patients with OSA who used continuous positive airway pressure (CPAP) therapy and 53% of controls with no history of OSA.

Various mechanisms could explain the relationship between OSA and atrial fibrillation. Apnea episodes are associated with surges in heart rate, which may trigger arrhythmia. Patients exert tremendous force to try to open occluded airways, which may lead to left atrial enlargement. Recurrent hypoxemia and hypercapnia irritate the myocardium, which also may trigger arrhythmia. In addition, untreated OSA may be associated with hypercoagulability, which heightens patients’ risk of cardioembolism.

A Single-Center Study

Researchers at Mayo Clinic compared strokes in patients with and without OSA. They examined data from patients who had their first ischemic stroke within one year after undergoing polysomnography. Among patients with OSA, 72% of strokes were of a cardioembolic mechanism. In the group without OSA, 33% were cardioembolic. “The frequency of cardioembolic stroke increased as OSA severity increased, and that relationship held after we adjusted for multiple vascular risk factors,” said Dr. Lipford. The relationship remained after accounting for history of atrial fibrillation or atrial flutter. The results suggest that there may be a high burden of undiagnosed atrial fibrillation in people with OSA, she said.

The advent of long-term cardiac monitoring has raised the question of who should receive monitoring to screen for occult atrial arrhythmia. “This is an expensive procedure that sometimes requires an invasive procedure,” said Dr. Lipford.

The American Heart Association/American Stroke Association guidelines in 2014 advised that 30-day monitoring is reasonable within six months of a cardioembolic stroke, but the statement does not guide neurologists as to which patients are the right candidates. Screening may be warranted in patients with OSA, Dr. Lipford said.

Studies have found that long-term monitoring detects atrial fibrillation. “The EMBRACE study used 30-day noninvasive monitoring and looked at patients who had cryptogenic stroke and in the first 24 hours of telemetry monitoring had no evidence of arrhythmia. Over that 30-day period, they picked up on atrial fibrillation in 16% of the patients studied. That compares to 3.2% of controls who underwent traditional medical follow up. The CRYSTAL AF study used an insertable cardiac monitor and looked at patients over one year. They picked up on atrial fibrillation in 12.4% of patients.” The percentage of patients with atrial fibrillation is “on the smaller side,” Dr. Lipford said. “But if we start those patients on anticoagulation therapy, they are getting a dramatically reduced risk of having a stroke, compared with maintaining them on the antiplatelet therapy.”

—Jake Remaly

Suggested Reading

Gami AS, Pressman G, Caples SM, et al. Association of atrial fibrillation and obstructive sleep apnea. Circulation. 2004;110(4):364-367.

Gladstone DJ, Spring M, Dorian P, et al. Atrial fibrillation in patients with cryptogenic stroke. N Engl J Med. 2014;370(26):2467-2477.

Kanagala R, Murali NS, Friedman PA, et al. Obstructive sleep apnea and the recurrence of atrial fibrillation. Circulation. 2003;107(20):2589-2594.

Lipford MC, Flemming KD, Calvin AD, et al. Associations between cardioembolic stroke and obstructive sleep apnea. Sleep. 2015;38(11):1699-1705.

Mansukhani MP, Calvin AD, Kolla BP, et al. The association between atrial fibrillation and stroke in patients with obstructive sleep apnea: a population-based case-control study. Sleep Med. 2013;14(3):243-246.

Mehra R, Benjamin EJ, Shahar E, et al. Association of nocturnal arrhythmias with sleep-disordered breathing: The Sleep Heart Health Study. Am J Respir Crit Care Med. 2006;173(8):910-916.

Sanna T, Diener HC, Passman RS, et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med. 2014;370(26):2478-2486.

BALTIMORE—Patients with stroke and obstructive sleep apnea (OSA) are more likely than patients without these conditions to have atrial fibrillation, said Melissa Lipford, MD, a neurologist and sleep specialist at Mayo Clinic in Rochester, Minnesota. If physicians detect atrial fibrillation in this patient population, the finding may lead to more effective preventive stroke treatment, Dr. Lipford said at the 32nd Annual Meeting of the Associated Professional Sleep Societies.

“In patients who present with cryptogenic stroke, if they have a known history of moderate to severe OSA, perhaps these are candidates where we would give higher consideration to doing long-term monitoring to screen for occult arrhythmia. If we find it and put them on anticoagulation therapy, they will be at a 40% to 70% reduced risk of having a stroke, compared with only 20% if we maintain antiplatelet therapy.”

Physicians must confirm that a patient has atrial fibrillation before starting anticoagulation therapy, however, she said. “We cannot just start them on warfarin because of the risk of bleeding. If you have patients on aspirin therapy, their risk of a major bleed is probably only 0.5% per year. The risk is doubled with warfarin in the lowest-risk patients. But if you tack on age, hypertension, and other risk factors, that goes up to almost a 12% per year risk with warfarin,” she said. “In every patient you have to do a risk–benefit analysis…. If you document atrial fibrillation, that risk of having a stroke is so high that the risk of a stroke outweighs the risks of anticoagulation in most cases.”

Potential Mechanisms

Dr. Lipford described a 65-year-old man with cryptogenic stroke who was found to have severe OSA. Although 24-hour telemetry monitoring showed no evidence of arrhythmia, he could be a candidate for 30-day noninvasive ambulatory heart monitoring, Dr. Lipford said.

“Typically, in these patients, we put them on aspirin and generally control their risk factors,” she said. “Knowing that this patient has severe OSA … we might consider more strongly long-term cardiac monitoring to help screen for occult atrial arrhythmia.”

Atrial fibrillation affects as many as six million people in the United States, including 9% of patients over age 65. It increases a person’s risk of stroke fivefold, Dr. Lipford said.

“Unfortunately, atrial fibrillation is commonly undetected,” she said. Many patients do not have symptoms. Patients may have paroxysmal disease. Some patients only have episodes at night.

Cardiogenic embolism accounts for between 20% and 30% of ischemic strokes each year. Most of these strokes are due to atrial fibrillation, Dr. Lipford said. About 60% of these strokes are severely disabling, and 20% result in death.

Gami and colleagues examined the prevalence of OSA in patients with and without atrial fibrillation. Patients with atrial fibrillation were more likely to have OSA, compared with patients without atrial fibrillation (49% vs 32%). Mansukhani et al found that in patients with OSA and a history of stroke, about 50% had a history of atrial fibrillation or atrial flutter, compared with 10.8% of patients with OSA and no history of stroke.

Data from the Sleep Heart Health Study indicate that patients with severe OSA have an increased risk of atrial fibrillation, compared with patients without sleep-disordered breathing (4.8% vs 0.9%).

After procedures such as cardioversion, patients with untreated OSA are more likely reconvert to atrial fibrillation, Dr. Lipford said. Kanagala and colleagues found that 82% of patients with untreated OSA had recurrence of atrial fibrillation at 12 months after cardioversion, compared with 42% of patients with OSA who used continuous positive airway pressure (CPAP) therapy and 53% of controls with no history of OSA.

Various mechanisms could explain the relationship between OSA and atrial fibrillation. Apnea episodes are associated with surges in heart rate, which may trigger arrhythmia. Patients exert tremendous force to try to open occluded airways, which may lead to left atrial enlargement. Recurrent hypoxemia and hypercapnia irritate the myocardium, which also may trigger arrhythmia. In addition, untreated OSA may be associated with hypercoagulability, which heightens patients’ risk of cardioembolism.

A Single-Center Study

Researchers at Mayo Clinic compared strokes in patients with and without OSA. They examined data from patients who had their first ischemic stroke within one year after undergoing polysomnography. Among patients with OSA, 72% of strokes were of a cardioembolic mechanism. In the group without OSA, 33% were cardioembolic. “The frequency of cardioembolic stroke increased as OSA severity increased, and that relationship held after we adjusted for multiple vascular risk factors,” said Dr. Lipford. The relationship remained after accounting for history of atrial fibrillation or atrial flutter. The results suggest that there may be a high burden of undiagnosed atrial fibrillation in people with OSA, she said.

The advent of long-term cardiac monitoring has raised the question of who should receive monitoring to screen for occult atrial arrhythmia. “This is an expensive procedure that sometimes requires an invasive procedure,” said Dr. Lipford.

The American Heart Association/American Stroke Association guidelines in 2014 advised that 30-day monitoring is reasonable within six months of a cardioembolic stroke, but the statement does not guide neurologists as to which patients are the right candidates. Screening may be warranted in patients with OSA, Dr. Lipford said.

Studies have found that long-term monitoring detects atrial fibrillation. “The EMBRACE study used 30-day noninvasive monitoring and looked at patients who had cryptogenic stroke and in the first 24 hours of telemetry monitoring had no evidence of arrhythmia. Over that 30-day period, they picked up on atrial fibrillation in 16% of the patients studied. That compares to 3.2% of controls who underwent traditional medical follow up. The CRYSTAL AF study used an insertable cardiac monitor and looked at patients over one year. They picked up on atrial fibrillation in 12.4% of patients.” The percentage of patients with atrial fibrillation is “on the smaller side,” Dr. Lipford said. “But if we start those patients on anticoagulation therapy, they are getting a dramatically reduced risk of having a stroke, compared with maintaining them on the antiplatelet therapy.”

—Jake Remaly

Suggested Reading

Gami AS, Pressman G, Caples SM, et al. Association of atrial fibrillation and obstructive sleep apnea. Circulation. 2004;110(4):364-367.

Gladstone DJ, Spring M, Dorian P, et al. Atrial fibrillation in patients with cryptogenic stroke. N Engl J Med. 2014;370(26):2467-2477.

Kanagala R, Murali NS, Friedman PA, et al. Obstructive sleep apnea and the recurrence of atrial fibrillation. Circulation. 2003;107(20):2589-2594.

Lipford MC, Flemming KD, Calvin AD, et al. Associations between cardioembolic stroke and obstructive sleep apnea. Sleep. 2015;38(11):1699-1705.

Mansukhani MP, Calvin AD, Kolla BP, et al. The association between atrial fibrillation and stroke in patients with obstructive sleep apnea: a population-based case-control study. Sleep Med. 2013;14(3):243-246.

Mehra R, Benjamin EJ, Shahar E, et al. Association of nocturnal arrhythmias with sleep-disordered breathing: The Sleep Heart Health Study. Am J Respir Crit Care Med. 2006;173(8):910-916.

Sanna T, Diener HC, Passman RS, et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med. 2014;370(26):2478-2486.

BALTIMORE—Patients with stroke and obstructive sleep apnea (OSA) are more likely than patients without these conditions to have atrial fibrillation, said Melissa Lipford, MD, a neurologist and sleep specialist at Mayo Clinic in Rochester, Minnesota. If physicians detect atrial fibrillation in this patient population, the finding may lead to more effective preventive stroke treatment, Dr. Lipford said at the 32nd Annual Meeting of the Associated Professional Sleep Societies.

“In patients who present with cryptogenic stroke, if they have a known history of moderate to severe OSA, perhaps these are candidates where we would give higher consideration to doing long-term monitoring to screen for occult arrhythmia. If we find it and put them on anticoagulation therapy, they will be at a 40% to 70% reduced risk of having a stroke, compared with only 20% if we maintain antiplatelet therapy.”

Physicians must confirm that a patient has atrial fibrillation before starting anticoagulation therapy, however, she said. “We cannot just start them on warfarin because of the risk of bleeding. If you have patients on aspirin therapy, their risk of a major bleed is probably only 0.5% per year. The risk is doubled with warfarin in the lowest-risk patients. But if you tack on age, hypertension, and other risk factors, that goes up to almost a 12% per year risk with warfarin,” she said. “In every patient you have to do a risk–benefit analysis…. If you document atrial fibrillation, that risk of having a stroke is so high that the risk of a stroke outweighs the risks of anticoagulation in most cases.”

Potential Mechanisms

Dr. Lipford described a 65-year-old man with cryptogenic stroke who was found to have severe OSA. Although 24-hour telemetry monitoring showed no evidence of arrhythmia, he could be a candidate for 30-day noninvasive ambulatory heart monitoring, Dr. Lipford said.

“Typically, in these patients, we put them on aspirin and generally control their risk factors,” she said. “Knowing that this patient has severe OSA … we might consider more strongly long-term cardiac monitoring to help screen for occult atrial arrhythmia.”

Atrial fibrillation affects as many as six million people in the United States, including 9% of patients over age 65. It increases a person’s risk of stroke fivefold, Dr. Lipford said.

“Unfortunately, atrial fibrillation is commonly undetected,” she said. Many patients do not have symptoms. Patients may have paroxysmal disease. Some patients only have episodes at night.

Cardiogenic embolism accounts for between 20% and 30% of ischemic strokes each year. Most of these strokes are due to atrial fibrillation, Dr. Lipford said. About 60% of these strokes are severely disabling, and 20% result in death.

Gami and colleagues examined the prevalence of OSA in patients with and without atrial fibrillation. Patients with atrial fibrillation were more likely to have OSA, compared with patients without atrial fibrillation (49% vs 32%). Mansukhani et al found that in patients with OSA and a history of stroke, about 50% had a history of atrial fibrillation or atrial flutter, compared with 10.8% of patients with OSA and no history of stroke.

Data from the Sleep Heart Health Study indicate that patients with severe OSA have an increased risk of atrial fibrillation, compared with patients without sleep-disordered breathing (4.8% vs 0.9%).

After procedures such as cardioversion, patients with untreated OSA are more likely reconvert to atrial fibrillation, Dr. Lipford said. Kanagala and colleagues found that 82% of patients with untreated OSA had recurrence of atrial fibrillation at 12 months after cardioversion, compared with 42% of patients with OSA who used continuous positive airway pressure (CPAP) therapy and 53% of controls with no history of OSA.

Various mechanisms could explain the relationship between OSA and atrial fibrillation. Apnea episodes are associated with surges in heart rate, which may trigger arrhythmia. Patients exert tremendous force to try to open occluded airways, which may lead to left atrial enlargement. Recurrent hypoxemia and hypercapnia irritate the myocardium, which also may trigger arrhythmia. In addition, untreated OSA may be associated with hypercoagulability, which heightens patients’ risk of cardioembolism.

A Single-Center Study

Researchers at Mayo Clinic compared strokes in patients with and without OSA. They examined data from patients who had their first ischemic stroke within one year after undergoing polysomnography. Among patients with OSA, 72% of strokes were of a cardioembolic mechanism. In the group without OSA, 33% were cardioembolic. “The frequency of cardioembolic stroke increased as OSA severity increased, and that relationship held after we adjusted for multiple vascular risk factors,” said Dr. Lipford. The relationship remained after accounting for history of atrial fibrillation or atrial flutter. The results suggest that there may be a high burden of undiagnosed atrial fibrillation in people with OSA, she said.

The advent of long-term cardiac monitoring has raised the question of who should receive monitoring to screen for occult atrial arrhythmia. “This is an expensive procedure that sometimes requires an invasive procedure,” said Dr. Lipford.

The American Heart Association/American Stroke Association guidelines in 2014 advised that 30-day monitoring is reasonable within six months of a cardioembolic stroke, but the statement does not guide neurologists as to which patients are the right candidates. Screening may be warranted in patients with OSA, Dr. Lipford said.

Studies have found that long-term monitoring detects atrial fibrillation. “The EMBRACE study used 30-day noninvasive monitoring and looked at patients who had cryptogenic stroke and in the first 24 hours of telemetry monitoring had no evidence of arrhythmia. Over that 30-day period, they picked up on atrial fibrillation in 16% of the patients studied. That compares to 3.2% of controls who underwent traditional medical follow up. The CRYSTAL AF study used an insertable cardiac monitor and looked at patients over one year. They picked up on atrial fibrillation in 12.4% of patients.” The percentage of patients with atrial fibrillation is “on the smaller side,” Dr. Lipford said. “But if we start those patients on anticoagulation therapy, they are getting a dramatically reduced risk of having a stroke, compared with maintaining them on the antiplatelet therapy.”

—Jake Remaly

Suggested Reading

Gami AS, Pressman G, Caples SM, et al. Association of atrial fibrillation and obstructive sleep apnea. Circulation. 2004;110(4):364-367.

Gladstone DJ, Spring M, Dorian P, et al. Atrial fibrillation in patients with cryptogenic stroke. N Engl J Med. 2014;370(26):2467-2477.

Kanagala R, Murali NS, Friedman PA, et al. Obstructive sleep apnea and the recurrence of atrial fibrillation. Circulation. 2003;107(20):2589-2594.

Lipford MC, Flemming KD, Calvin AD, et al. Associations between cardioembolic stroke and obstructive sleep apnea. Sleep. 2015;38(11):1699-1705.

Mansukhani MP, Calvin AD, Kolla BP, et al. The association between atrial fibrillation and stroke in patients with obstructive sleep apnea: a population-based case-control study. Sleep Med. 2013;14(3):243-246.

Mehra R, Benjamin EJ, Shahar E, et al. Association of nocturnal arrhythmias with sleep-disordered breathing: The Sleep Heart Health Study. Am J Respir Crit Care Med. 2006;173(8):910-916.

Sanna T, Diener HC, Passman RS, et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med. 2014;370(26):2478-2486.

BALTIMORE—Older men who nap for more than an hour per day are more likely to develop Parkinson’s disease over 11 years of follow-up, compared with those who nap for less than an hour per day and do not have excessive daytime sleepiness, according to a study described at the 32nd Annual Meeting of the Associated Professional Sleep Societies.

Self-reported daytime sleepiness alone was not associated with increased risk, said Yue Leng, PhD, a postdoctoral researcher at the University of California, San Francisco.

The findings suggest that objective measures of napping might be valuable preclinical markers of Parkinson’s disease.

The mechanism underlying the association is unclear. It is possible that the ongoing degeneration in brain regions involved in the 24-hour sleep–wake cycle leads to increased napping in people who later develop Parkinson’s disease, she said.

“Excessive daytime sleepiness and daytime napping are common in older adults, especially those with Parkinson’s disease,” Dr. Leng said. Whether excessive daytime sleepiness or napping precedes the development of Parkinson’s disease and may be risk factors is not well understood, however. “There is a lack of objectively measured naps and also a lack of longitudinal studies. In fact, we are unaware of any longitudinal studies that have used objectively measured napping in relation to Parkinson’s disease risk.”

To examine the longitudinal association between objectively measured napping duration and risk of Parkinson’s disease, Dr. Leng and colleagues analyzed data from the Osteoporotic Fractures in Men Study (MrOS), a large, longitudinal, multicenter study of community-dwelling older men. They excluded men with Parkinson’s disease at baseline. The analysis included data from more than 2,900 men who had napping and sleep measures at baseline between 2003 and 2005 and were followed up for development of Parkinson’s disease over 11 years.

The investigators used actigraphy to measure napping. Participants wore a sleep watch on the dominant wrist for at least five consecutive 24-hour periods. The researchers defined napping as having at least five consecutive minutes of inactivity outside of the main sleep period. They defined excessive daytime sleepiness as a score greater than 10 on the Epworth Sleepiness Scale.

The researchers identified Par­kinson’s disease using physician diagnosis or Parkinson’s disease medication use. Their analysis adjusted for age, BMI, smoking, physical activity, depression, comorbidities, global cognition scores, medication use, and nighttime sleep variables (ie, efficiency, duration, and apnea–hypopnea index).

“The highest risk was in those who reported daytime sleepiness and had objective napping for at least an hour per day,” Dr. Leng said. These participants had more than twice the risk of developing Parkinson’s disease, compared with a reference group that did not have daytime sleepiness and napped for less than one hour per day (odds ratio, 2.52).

Participants who napped for at least an hour per day but did not report excessive daytime sleepiness also had increased risk (odds ratio, 1.96).

The results indicate that objectively measured napping, rather than self-reported excessive daytime sleepiness, is important for Parkinson’s disease risk, Dr. Leng said.

Sensitivity analyses that excluded patients who developed Parkinson’s disease within two years after baseline and only included physician-confirmed cases of Parkinson’s disease had similar results.

Actigraphy is limited in its ability to differentiate between napping and inactivity, Dr. Leng noted. In addition, the results cannot be generalized to women and younger populations, she said.

—Jake Remaly

Suggested Reading

Leng Y, Goldman SM, Cawthon PM, et al. Excessive daytime sleepiness, objective napping and 11-year risk of Parkinson’s disease in older men. Int J Epidemiol. 2018 Jun 4 [Epub ahead of print].

BALTIMORE—Older men who nap for more than an hour per day are more likely to develop Parkinson’s disease over 11 years of follow-up, compared with those who nap for less than an hour per day and do not have excessive daytime sleepiness, according to a study described at the 32nd Annual Meeting of the Associated Professional Sleep Societies.

Self-reported daytime sleepiness alone was not associated with increased risk, said Yue Leng, PhD, a postdoctoral researcher at the University of California, San Francisco.

The findings suggest that objective measures of napping might be valuable preclinical markers of Parkinson’s disease.

The mechanism underlying the association is unclear. It is possible that the ongoing degeneration in brain regions involved in the 24-hour sleep–wake cycle leads to increased napping in people who later develop Parkinson’s disease, she said.

“Excessive daytime sleepiness and daytime napping are common in older adults, especially those with Parkinson’s disease,” Dr. Leng said. Whether excessive daytime sleepiness or napping precedes the development of Parkinson’s disease and may be risk factors is not well understood, however. “There is a lack of objectively measured naps and also a lack of longitudinal studies. In fact, we are unaware of any longitudinal studies that have used objectively measured napping in relation to Parkinson’s disease risk.”

To examine the longitudinal association between objectively measured napping duration and risk of Parkinson’s disease, Dr. Leng and colleagues analyzed data from the Osteoporotic Fractures in Men Study (MrOS), a large, longitudinal, multicenter study of community-dwelling older men. They excluded men with Parkinson’s disease at baseline. The analysis included data from more than 2,900 men who had napping and sleep measures at baseline between 2003 and 2005 and were followed up for development of Parkinson’s disease over 11 years.

The investigators used actigraphy to measure napping. Participants wore a sleep watch on the dominant wrist for at least five consecutive 24-hour periods. The researchers defined napping as having at least five consecutive minutes of inactivity outside of the main sleep period. They defined excessive daytime sleepiness as a score greater than 10 on the Epworth Sleepiness Scale.

The researchers identified Par­kinson’s disease using physician diagnosis or Parkinson’s disease medication use. Their analysis adjusted for age, BMI, smoking, physical activity, depression, comorbidities, global cognition scores, medication use, and nighttime sleep variables (ie, efficiency, duration, and apnea–hypopnea index).

“The highest risk was in those who reported daytime sleepiness and had objective napping for at least an hour per day,” Dr. Leng said. These participants had more than twice the risk of developing Parkinson’s disease, compared with a reference group that did not have daytime sleepiness and napped for less than one hour per day (odds ratio, 2.52).

Participants who napped for at least an hour per day but did not report excessive daytime sleepiness also had increased risk (odds ratio, 1.96).

The results indicate that objectively measured napping, rather than self-reported excessive daytime sleepiness, is important for Parkinson’s disease risk, Dr. Leng said.

Sensitivity analyses that excluded patients who developed Parkinson’s disease within two years after baseline and only included physician-confirmed cases of Parkinson’s disease had similar results.

Actigraphy is limited in its ability to differentiate between napping and inactivity, Dr. Leng noted. In addition, the results cannot be generalized to women and younger populations, she said.

—Jake Remaly

Suggested Reading

Leng Y, Goldman SM, Cawthon PM, et al. Excessive daytime sleepiness, objective napping and 11-year risk of Parkinson’s disease in older men. Int J Epidemiol. 2018 Jun 4 [Epub ahead of print].

BALTIMORE—Older men who nap for more than an hour per day are more likely to develop Parkinson’s disease over 11 years of follow-up, compared with those who nap for less than an hour per day and do not have excessive daytime sleepiness, according to a study described at the 32nd Annual Meeting of the Associated Professional Sleep Societies.

Self-reported daytime sleepiness alone was not associated with increased risk, said Yue Leng, PhD, a postdoctoral researcher at the University of California, San Francisco.

The findings suggest that objective measures of napping might be valuable preclinical markers of Parkinson’s disease.

The mechanism underlying the association is unclear. It is possible that the ongoing degeneration in brain regions involved in the 24-hour sleep–wake cycle leads to increased napping in people who later develop Parkinson’s disease, she said.

“Excessive daytime sleepiness and daytime napping are common in older adults, especially those with Parkinson’s disease,” Dr. Leng said. Whether excessive daytime sleepiness or napping precedes the development of Parkinson’s disease and may be risk factors is not well understood, however. “There is a lack of objectively measured naps and also a lack of longitudinal studies. In fact, we are unaware of any longitudinal studies that have used objectively measured napping in relation to Parkinson’s disease risk.”

To examine the longitudinal association between objectively measured napping duration and risk of Parkinson’s disease, Dr. Leng and colleagues analyzed data from the Osteoporotic Fractures in Men Study (MrOS), a large, longitudinal, multicenter study of community-dwelling older men. They excluded men with Parkinson’s disease at baseline. The analysis included data from more than 2,900 men who had napping and sleep measures at baseline between 2003 and 2005 and were followed up for development of Parkinson’s disease over 11 years.

The investigators used actigraphy to measure napping. Participants wore a sleep watch on the dominant wrist for at least five consecutive 24-hour periods. The researchers defined napping as having at least five consecutive minutes of inactivity outside of the main sleep period. They defined excessive daytime sleepiness as a score greater than 10 on the Epworth Sleepiness Scale.

The researchers identified Par­kinson’s disease using physician diagnosis or Parkinson’s disease medication use. Their analysis adjusted for age, BMI, smoking, physical activity, depression, comorbidities, global cognition scores, medication use, and nighttime sleep variables (ie, efficiency, duration, and apnea–hypopnea index).

“The highest risk was in those who reported daytime sleepiness and had objective napping for at least an hour per day,” Dr. Leng said. These participants had more than twice the risk of developing Parkinson’s disease, compared with a reference group that did not have daytime sleepiness and napped for less than one hour per day (odds ratio, 2.52).

Participants who napped for at least an hour per day but did not report excessive daytime sleepiness also had increased risk (odds ratio, 1.96).

The results indicate that objectively measured napping, rather than self-reported excessive daytime sleepiness, is important for Parkinson’s disease risk, Dr. Leng said.

Sensitivity analyses that excluded patients who developed Parkinson’s disease within two years after baseline and only included physician-confirmed cases of Parkinson’s disease had similar results.

Actigraphy is limited in its ability to differentiate between napping and inactivity, Dr. Leng noted. In addition, the results cannot be generalized to women and younger populations, she said.

—Jake Remaly

Suggested Reading

Leng Y, Goldman SM, Cawthon PM, et al. Excessive daytime sleepiness, objective napping and 11-year risk of Parkinson’s disease in older men. Int J Epidemiol. 2018 Jun 4 [Epub ahead of print].