Impact of sleep apnea and treatments on cardiovascular disease

Cardiovascular diseases (CVDs) are the leading causes of mortality worldwide, accounting for nearly 18 million deaths per year. Among other considerations, treating CVDs requires better understanding their risk factors. Sleep-disordered breathing, especially obstructive sleep apnea (OSA), is a likely contributor to several CVDs. We review key epidemiological data that addresses the link between OSA and cardiovascular outcomes such as hypertension, atrial fibrillation (AF), stroke, atherosclerosis, and heart failure (HF), and proposed pathophysiological mechanisms underlying this association. There are several biological pathways linking OSA and an increased propensity to cardiovascular diseases, and we discuss the evidence on the benefits of treatments of OSA on the prevalence of cardiovascular complications.

Sleep Apnea - Obstructive - Hypertension - Stroke - Atrial Fibrillation - Continuous Positive Airway Pressure - Weight Loss

Publikationsverlauf

Eingereicht: 25. Juni 2021

Angenommen: 01. November 2021

Artikel online veröffentlicht:
01. Dezember 2023

• REFERENCES

• 1 Sarkar P, Mukherjee S, Chai-Coetzer CL, McEvoy RD. The epidemiology of obstructive sleep apnoea and cardiovascular disease. J Thorac Dis. 2018 Dec;10(Suppl 34):S4189-S200.
• 2 Sânchez-de-la-Torre M, Campos-Rodriguez F, Barbé F. Obstructive sleep apnoea and cardiovascular disease. Lancet Respir Med. 2013 Mar;1(1):61-72.
• 3 Kohler M, Stradling JR. Mechanisms of vascular damage in obstructive sleep apnea. Nat Rev Cardiol. 2010 Dec;7(12):677-85.
• 4 Canadian Agency for Drugs and Technologies in Health (CADTH). Portable monitoring devices for diagnosis of obstructive sleep apnea at home: review of accuracy, cost- effectiveness, guidelines, and coverage in Canada. CADTH Technol Overv. 2010 Dec;1(4):e0123.
• 5 World Health Organization (WHO). Cardiovascular diseases [Internet]. Geneva: WHO; 2017; [access in 2019 Nov 26]. Available from: https://www. who.int/en/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds)
• 6 Peppard PE, Young T, Palta M, Skatrud J. Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med. 2000 May;342(19):1378-4.
• 7 Ramar K, Caples SM. Cardiovascular consequences of obese and nonobese obstructive sleep apnea. Med Clin North Am. 2010 May;94(3):465-78.
• 8 Gottlieb DJ, Yenokyan G, Newman AB, O’Connor GT, Punjabi NM, Quan FS, et al. Prospective study of obstructive sleep apnea and incident coronary heart disease and heart failure: the sleep heart health study. Circulation. 2010 Jul;122(4):352-60.
• 9 Xu S, Wan Y, Xu M, Ming J, Xing Y, An F, et al. The association between obstructive sleep apnea and metabolic syndrome: a systematic review and meta-analysis. BMC Pulm Med. 2015;15:105.
• 10 Selim BJ, Ramar K. Management of sleep apnea syndromes in heart failure. Sleep Med Clin. 2017 Mar;12(1):107-21.
• 11 Stowhas AC, Namdar M, Biaggi P, Russi EW, Bloch KE, Stradling JR, et al. The effect of simulated obstructive apnea and hypopnea on aortic diameter and BP. Chest. 2011 Sep;140(3):675-80.
• 12 Virolainen J, Ventila M, Turto H, Kupari M. Effect of negative intrathoracic pressure on left ventricular pressure dynamics and relaxation. J Appl Physiol (1985). 1995 Aug;79(2):455-60.
• 13 Orban M, Bruce CJ, Pressman GS, Leinveber P, Romero-Corral A, Korinek J, et al. Dynamic changes of left ventricular performance and left atrial volume induced by the Mueller maneuver in healthy young adults and implications for obstructive sleep apnea, atrial fibrillation, and heart failure. Am J Cardiol. 2008 Dec;102(11):1557-61.
• 14 Haïssaguerre M, Jais P, Shah DC, Takahashi A, Hocini M, Quiniou G, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998 Sep;339(10):659-66.
• 15 Caples SM, Somers VK. Sleep disordered breathing and atrial fibrillation. Progress in cardiovascular diseases. 2009 Mar/Apr;51(5):411.
• 16 Bradley TD, Hall MJ, Ando SI, Floras JS. Hemodynamic effects of simulated obstructive apneas in humans with and without heart failure. Chest. 2001 Jun;119(6):1827-35.
• 17 Korantzopoulos P, Kolettis TM, Galaris D, Goudevenos JA. The role of oxidative stress in the pathogenesis and perpetuation of atrial fibrillation. Int J Cardiol. 2007 Feb;115(2):135-43.
• 18 Goudis CA, Ketikoglou DG. Obstructive sleep and atrial fibrillation: pathophysiological mechanisms and therapeutic implications. Int J Cardiol. 2017 Mar;230:293-300.
• 19 Chung MK, Martin DO, Sprecher D, Wazni O, Kanderian A, Carnes CA, et al. C-reactive protein elevation in patients with atrial arrhythmias: inflammatory mechanisms and persistence of atrial fibrillation. Circulation. 2001 Dec;104(24):2886-91.
• 20 Shamsuzzaman AS, Winnicki M, Lanfranchi P, Wolk R, Kara T, Accurso V, et al. Elevated C-reactive protein in patients with obstructive sleep apnea. Circulation. 2002 May;105(21):2462-4.
• 21 Skalidis EI, Hamilos MI, Karalis IK, Chlouverakis G, Kochiadakis GE, Vardas PE. Isolated atrial microvascular dysfunction in patients with lone recurrent atrial fibrillation. J Am Coll Cardiol. 2008;51(21):2053-7.
• 22 Pepin JL, Levy P. Pathophysiology of cardiovascular risk in sleep apnea syndrome. Rev Neurol. 2002 Sep;158(8-9):785-97.
• 23 Tkacova R, Hall MJ, Rutherford R, Floras JS, Bradley TD. Effect of continuous positive airway pressure on nocturnal blood pressure in patients with heart failure and obstructive sleep apnea. Circulation. 1996;94:I340.
• 24 Tsai CT, Chiang FT, Tseng CD, Hwang JJ, Kuo KT, Wu CK, et al. Increased expression of mineralocorticoid receptor in human atrial fibrillation and a cellular model of atrial fibrillation. J Am Coll Cardiol. 2010 Feb;55(8):758-70.
• 25 Spaak J, Egri ZJ, Kubo T, Yu E, Ando SI, Kaneko Y, et al. Muscle sympathetic nerve activity during wakefulness in heart failure patients with and without sleep apnea. Hypertension. 2005 Dec;46(6):1327-32.
• 26 Goldberger JJ, Cain ME, Hohnloser SH, Kadish AH, Knight BP, Lauer MS, et al. American Heart Association/American College of Cardiology Foundation/Heart Rhythm Society Scientific Statement on noninvasive risk stratification techniques for identifying patients at risk for sudden cardiac death. Circulation. 2008 Sep;118(14):1497-518.
• 27 Floras JS. Should sleep apnoea be a specific target of therapy in chronic heart failure? Heart. 2009;95(13):1041-6.
• 28 Fung JW, Li TS, Choy DK, Yip GWK, Ko FWS, Sanderson JE, et al. Severe obstructive sleep apnea is associated with left ventricular diastolic dysfunction. Chest. 2002 Feb;121(2):422-9.
• 29 Laaban JP, Pascal-Sebaoun S, Bloch E, Orvoen-Frija E, Oppert JM, Huchon G. Left ventricular systolic dysfunction in patients with obstructive sleep apnea syndrome. Chest. 2002 Oct;122(4):1133-8.
• 30 Oliveira W, Campos O, Lira-Filho EB, Cintra FD, Vieira M, Ponchirolli A, et al. Left atrial volume and function in patients with obstructive sleep apnea assessed by real-time three-dimensional echocardiography. J Am Soc Echocardiogr. 2008 Dec;21(12):1355-61.
• 31 Yumino D, Redolfi S, Ruttanaumpawan P, Su MC, Smith S, Newton GE, et al. Nocturnal rostral fluid shift: a unifying concept for the pathogenesis of obstructive and central sleep apnea in men with heart failure. Circulation. 2010 Apr;121(14):1598-605.
• 32 Lorenzi-Filho G, Drager LF. Obstructive sleep apnea and atherosclerosis: a new paradigm. Am J Respir Crit Care Med. 2007 Jun;175(12):1219-21.
• 33 Lyons OD, Clodagh MR. Sleep apnea and stroke. Can J Cardiol. 2015;31(7):918-27.
• 34 Lévy P, Pépin JL, Arnaud C, Tamisier R, Borel JC, Dematteis M, et al. Intermittent hypoxia and sleep-disordered breathing: current concepts and perspectives. Eur Respir J. 2008 Oct;32(4):1082-95.
• 35 Min LI, Xiaoying LI, Yan LU. Obstructive sleep apnea syndrome and metabolic diseases. Endocrinology. 2018 Jul;159(7):2670-5.
• 36 Vgontzas AN, Papanicolaou DA, Bixler EO, Hopper K, Lotsikas A, Lin HM, et al. Sleep apnea and daytime sleepiness and fatigue: relation to visceral obesity, insulin resistance, and hypercytokinemia. J Clin Endocrinol Metab. 2000 Mar;85(3):1151-8.
• 37 Pedrosa RP, Drager LF, Gonzaga CC, Hopper K, Lotsikas A, Lin HM, et al. Obstructive sleep apnea: the most common secondary cause of hypertension associated with resistant hypertension. Hypertension. 2011 Nov;58(5):811-7.
• 38 Goncalves SC, Martinez D, Gus M, Abreu-Silva EO, Bertoluci C, Dutra I, et al. Obstructive sleep apnea and resistant hypertension: a casecontrol study. Chest. 2007 Dec;132(6):1858-62.
• 39 Young T, Palta M, Dempsey J, Peppard PE, Nieto FJ, Hla KM. Burden of sleep apnea: rationale, design, and major findings of the Wisconsin Sleep Cohort study. WMJ. 2009 Aug;108(5):246-9.
• 40 Hou H, Zhao Y, Yu W, Dong H, Xue X, Ding J, et al. Association of obstructive sleep apnea with hypertension: a systematic review and meta-analysis. J Glob Health. 2018 Jun;8(1):010405.
• 41 Haas DC, Foster GL, Javier Nieto F, Redline S, Resnick HE, Robbins JA, et al. Age-dependent associations between sleep-disordered breathing and hypertension: importance of discriminating between systolic/diastolic hypertension and isolated systolic hypertension in the Sleep Heart Health Study. Circulation. 2005 Feb;111(5):614-21.
• 42 Glasser M, Bailey N, McMillan A, Goff E, Morrell MJ. Sleep apnoea in older people. Breathe. 2011;7:248-56.
• 43 Gami AS, Pressman G, Caples SM, Kanagala R, Gard JJ, Davison DE, et al. Association of atrial fibrillation and obstructive sleep apnea. Circulation. 2004 Jul;110(4):364-7.
• 44 Uchôa CHG, Danzi-Soares NJ, Nunes FS, Souza AAL, Nerbass FB, Pedrosa RP, et al. Impact of OSA on cardiovascular events after coronary artery bypass surgery. Chest. 2015 May;147(5):1352-60.
• 45 Wolk R, Kara T, Somers VK. Sleep-disordered breathing and cardiovascular disease. Circulation. 2003 Jul;108(1):9-12.
• 46 Mehra R, Benjamin EJ, Shahar E, Gottlieb DJ, Nawabit R, Kirchner HL, et al. Association of nocturnal arrhythmias with sleep disordered breathing: the sleep heart health study. Am J Respir Crit Care Med. 2006 Apr;173(8):910-6.
• 47 Youssef I, Kamran H, Yacoub M, Patel N, Goulbourne C, Kumar S, et al. Obstructive sleep apnea as a risk factor for atrial fibrillation: a metaanalysis. J Sleep Disord Ther. 2018;7(1):282.
• 48 Lorenzi Filho G, Genta PR, Pedrosa RP, Drager LF, Martinez D. Cardiovascular consequences of obstructive sleep apnea syndrome. J Bras Pneumol. 2010;36(Suppl 2):38-42.
• 49 Mehra R, Stone KL, Varosy PD, Hoffman AR, Marcus GM, Blackwell T, et al. Nocturnal arrhythmias across a spectrum of obstructive and central sleep-disordered breathing in older men: outcomes of sleep disorders in older men (MrOS sleep) study. Arch Intern Med. 2009 Jun;169(12):1147-55.
• 50 Holmqvist F, Guan N, Zhu Z, Kowey PR, Allen LA, Fonarow GC, et al. Impact of obstructive sleep apnea and continuous positive airway pressure therapy on outcomes in patients with atrial fibrillation: results from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). Am Heart J. 2015;169(5):647.e2-54.e2.
• 51 Abumuamar AM, Dorian P, Newman D, Shapiro CM. The prevalence of obstructive sleep apnea in patients with atrial fibrillation. Clin Cardiol. 2018 May;41(5):601-7.
• 52 Benjafield AV, Ayas NT, Eastwood PR, Heinzer R, Ip MSM, Morell MJ, et al. Estimation of the global prevalence and burden of obstructive sleep apnoea: a literature based analysis. Lancet Respir Med. 2019 Aug;7(8):687-98.
• 53 Dong R, Dong Z, Liu H, Shi F, Du J. Prevalence, risk factors, outcomes, and treatment of obstructive sleep apnea in patients with cerebrovascular disease: a systematic review. J Stroke Cerebrovasc Dis. 2018 Jun;27(6):1471-80.
• 54 Johnson KG, Johnson DC. Frequency of sleep apnea in stroke and TIA patients: a meta-analysis. J Clin Sleep Med. 2010 Apr;6(2):131-7.
• 55 Wu Z, Chen F, Yu F, Wang Y, Guo Z. A meta-analysis of obstructive sleep apnea in patients with cerebrovascular disease. Sleep Breath. 2018 Sep;22(3):729-42.
• 56 Wang X, Ouyang Y, Wang Z, Zhao G, Liu L, Bi Y. Obstructive sleep apnea and risk of cardiovascular disease and all-cause mortality: a meta-analysis of prospective cohort studies. Int J Cardiol. 2013 Nov;169(3):207-14.
• 57 Li M, Hou W, Zhang X, Tang Z. Obstructive sleep apnea and risk of stroke: a meta- analysis of prospective studies. Int J Cardiol. 2014 Mar;172(2):466-9.
• 58 Somuncu MU, Bulut U, Karakurt H, Utkusavas A, Akbay E, Kilinc FK. The relationship between obstructive sleep apnea and coronary plaque: a coronary computed tomographic angiography study. Acta Cardiol Sin. 2019;35(3):325-34.
• 59 Drager LF, Bortolotto LA, Krieger EM, Lorenzi-Filho G. Additive effects of obstructive sleep apnea and hypertension on early markers of carotid atherosclerosis. Hypertension. 2009 Jan;53(1):64-9.
• 60 Chadda KR, Fazmin IT, Ahmad S, Valli H, Edling CE, Haung CLH, et al. Arrhythmogenic mechanisms of obstructive sleep apnea in heart failure patients. Sleep. 2018 Sep;41(9):zsy136.
• 61 Shahar E, Whitney CW, Redline S, Lee ET, Newman AB, Nieto FJ, et al. Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med. 2001 Jan;163(1):19-25.
• 62 Khattak HK, Hayat F, Pamboukian SV, Hahn HS, Schwartz BP, Stein PK. Obstructive sleep apnea in heart failure: review of prevalence, treatment with continuous positive airway pressure, and prognosis. Tex Heart Inst J. 2018 Jun;45(3):151-61.
• 63 Wachter R, Lüthje L, Klemmstein D, Lüers C, Stahrenberg R, Edelmann F, et al. Impact of obstructive sleep apnoea on diastolic function. Eur Respir J. 2012 Feb;41(2):376-83.
• 64 Martínez-García M, Capote F, Campos-Rodriguez F, Lloberes P, Díaz MJ, Somoza M, et al. Effect of CPAP on blood pressure in patients with obstructive sleep apnea and resistant hypertension: the HIPARCO randomized clinical trial. JAMA. 2013 Dec;310(22):2407-15.
• 65 Montesi SB, Edwards BA, Malhotra A, Bakker JP. The effect of continuous positive airway pressure treatment on blood pressure: a systematic review and meta-analysis of randomized controlled trials. J Clin Sleep Med. 2012 Oct;8(5):587-96.
• 66 Liu L, Cao Q, Guo Z, Dai Q. Continuous positive airway pressure in patients with obstructive sleep apnea and resistant hypertension: a meta-analysis of randomized controlled trials. J Clin Hypertens. 2016 Feb;18(2):153-8.
• 67 Iftikhar IH, Valentine CW, Bittencourt LR, Cohen DL, Fedson AC, Gíslason T, et al. Effects of continuous positive airway pressure on blood pressure in patients with resistant hypertension and obstructive sleep apnea: a metaanalysis. J Hypertens. 2014 Dec;32(12):2341-50.
• 68 Haentjens P, Van Meerhaeghe A, Moscariello A, Weerdt S, Poppe K, Dupont A, et al. The impact of continuous positive airway pressure on blood pressure in patients with obstructive sleep apnea syndrome: evidence from a meta-analysis of placebo-controlled randomized trials. Arch Intern Med. 2007 Apr;167(8):757-64.
• 69 Fava C, Dorigoni S, Vedove DF, Danese E, Montagnana M, Guidi GC, et al. Effect of CPAP on blood pressure in patients with OSA/hypopnea: a systematic review and meta-analysis. Chest. 2014 Apr;145(4):762-71.
• 70 Durán-Cantolla J, Aizpuru F, Martínez-Null C, Barbé-Illa F. Obstructive sleep apnea/hypopnea and systemic hypertension. Sleep Med Rev. 2009 Oct;13(5):323-31.
• 71 Bakker JP, Edwards BA, Gautam SP, Montesi SB, Durân-Cantolla J, Barandiarân FA, et al. Blood pressure improvement with continuous positive airway pressure is independent of obstructive sleep apnea severity. J Clin Sleep Med. 2014 Apr;10(4):365-9.
• 72 Pedrosa RP, Drager LF, Paula LK, Amaro ACS, Bortolotto LA, Lorenzi- Filho G. Effects of OSA treatment on BP in patients with resistant hypertension: a randomized trial. Chest. 2013 Nov;144(5):1487-94.
• 73 Qureshi WT, Nasir UB, Alqalyoobi S, O’Neal WT, Mawri S, Sabbagh S, et al. Meta- analysis of continuous positive airway pressure as a therapy of atrial fibrillation in obstructive sleep apnea. Am J Cardiol. 2015 Dec;116(11):1767-73.
• 74 Bradley TD, Hall MJ, Ando SI, Floras JS. Hemodynamic effects of simulated obstructive apneas in humans with and without heart failure. Chest. 2001 Jun;119(6):1827-35.
• 75 Kanagala R, Murali NS, Friedman PA, Naser A, Gersh BJ, Ballman KV, et al. Obstructive sleep apnea and the recurrence of atrial fibrillation. Circulation. 2003 May;107(20):2589-94.
• 76 Tung P, Anter E. Atrial fibrillation and sleep apnea: Considerations for a dual epidemic. J Atr Fibrillation. 2016 Apr/May;8(6):1283.
• 77 Marulanda-Londoño E, Chaturvedi E. The interplay between obstructive sleep apnea and atrial fibrillation. Front Neurol. 2017 Dec;8:668.
• 78 McEvoy RD, Antic NA, Heeley E, Luo Y, Ou Q, Zhang X, et al. CPAP for prevention of cardiovascular events in obstructive sleep apnea. N Eng J Med. 2016 Sep;375(10):919-31.
• 79 Hsu CY, Vennelle M, Li HY, Engleman HM, Dennis MS, Douglas NJ. Sleep-disordered breathing after stroke: a randomised controlled trial of continuous positive airway pressure. J Neurol Neurosurg Psychiatry. 2006 oct;77(10):1143-9.
• 80 Drager LF, Bortolotto LA, Figueiredo AC, Krieger EM, Lorenzi GF. Effects of continuous positive airway pressure on early signs of atherosclerosis in obstructive sleep apnea. Am J Respir Crit Care Med. 2007 Oct;176(7):706-12.
• 81 Baessler A, Nadeem R, Harvey M, Madbouly E, Younus A, Sajid H, et al. Treatment for sleep apnea by continuous positive airway pressure improves levels of inflammatory markers - a meta-analysis. J Inflamm (Lond). 2013 Mar;10:13.
• 82 Kohler M, Craig S, Pepperell JC, Nicoll D, Bratton DJ, Nunn AJ, et al. CPAP improves endothelial function in patients with minimally symptomatic OSA: results from a subset study of the MOSAIC trial. Chest. 2013 Sep;144(3):896-902.
• 83 Kohler M, Stoewhas AC, Ayers L, Senn O, Bloch KE, Russi EW, et al. Effects of continuous positive airway pressure therapy withdrawal in patients with obstructive sleep apnea: a randomized controlled trial. Am J Respir Crit Care Med. 2011 Nov;184(10):1192-9.
• 84 Kaneko Y, Floras JS, Usui K, Plante J, Tkacova R, Kubo T, et al. Cardiovascular effects of continuous positive airway pressure in patients with heart failure and obstructive sleep apnea. N Engl J Med. 2003 Mar;348(13):1233-41.
• 85 Shim CY, Kim D, Park S, Lee CJ, Cho HJ, Ha JW, et al. Effects of continuous positive airway pressure therapy on left ventricular diastolic function: a randomised, sham-controlled clinical trial. Eur Respir J. 2018 Jan;51(2):1701774.
• 86 Somers VK, White DP, Amin R, Abraham WT, Costa F, Culebras A, et al. Sleep apnea and cardiovascular disease: an American Heart Association/American College of Cardiology Foundation Scientific Statement from the American Heart Association Council for high blood pressure research professional education committee, council on clinical cardiology, stroke council, and council on cardiovascular nursing. J Am Coll Cardiol. 2008 Aug;52(8):686-717.
• 87 Yaggi HK, Concato J, Kernan WN, Lichtman JH, Brass LM, Mohsenin V. Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med. 2005 Nov;353(19):2034-41.
• 88 Kasai T, Narui K, Dohi T, Yanagisawa N, Ishiwata S, Ohno M, et al. Prognosis of patients with heart failure and obstructive sleep apnea treated with continuous positive airway pressure. Chest. 2008 Mar;133(3):690-6.
• 89 Naughton MT, Kee K. Sleep apnoea in heart failure: to treat or not to treat? Respirology. 2017 Feb;22(2):217-29.
• 90 Mansfield DR, Gollogly NC, Kaye DM, Richardson M, Bergin P, Naughton MT. Controlled trial of continuous positive airway pressure in obstructive sleep apnea and heart failure. Am J Respir Crit Care Med. 2004 Feb;169(3):361-6.
• 91 Wang H, Parker JD, Newton GE, Floras JS, Mak S, Chiu KL, et al. Influence of obstructive sleep apnea on mortality in patients with heart failure. J Am Coll Cardiol. 2007 Apr;49(15):1625-31.
• 92 Labarca G, Dreyse J, Drake L, Jorquera J, Barbe F. Efficacy of continuous positive airway pressure (CPAP) in the prevention of cardiovascular events in patients with obstructive sleep apnea: systematic review and meta-analysis. Sleep Med Rev. 2020 Aug;52:101312.
• 93 Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, et al. HFSA 2010 comprehensive heart failure practice guideline. J Card Fail. 2010 Jun;16(6):e1-e194.
• 94 Mokhlesi B, Ayas NT. Cardiovascular events in obstructive sleep apnea - can CPAP therapy SAVE lives? N Engl J Med. 2016 Sep;375(10):994-6.
• 95 Pack AI, Magalang UJ, Singh B, Kuna ST, Keenan BT, Maislin G. Randomized clinical trials of cardiovascular disease in obstructive sleep apnea: understanding and overcoming bias. Sleep. 2021 Feb;44(2):zsaa229. https://doi.org/10.1093/sleep/zsaa229
• 96 Aiello KD, Caughey WG, Nelluri B, Sharma A, Mookadam F, Mookadam M. Effect of exercise training on sleep apnea: a systematic review and meta-analysis. Respir Med. 2016 Jul;116:85-92.
• 97 Araghi MH, Chen YF, Jagielski A, Choudhury S, Banerjee D, Hussain S, et al. Effectiveness of lifestyle interventions on obstructive sleep apnea (OSA): systematic review and meta-analysis. Sleep. 2013 Oct;36(10):1553-62.
• 98 Iftikhar IH, Bittencourt L, Youngstedt SD, Ayas N, Cistulli P, Schwab R, et al. Comparative efficacy of CPAP, MADs, exercise-training, and dietary weight loss for sleep apnea: a network meta-analysis. Sleep Med. 2017 Feb;30:7-14.
• 99 Mitchell LJ, Davidson ZE, Bonham M, O’Driscoll DM, Hamilton GS, Truby H. Weight loss from lifestyle interventions and severity of sleep apnoea: a systematic review and meta-analysis. Sleep Med. 2014 Oct;15(10):1173-83.
• 100 Ng WL, Stevenson CE, Wong E, Tanamas S, Boelsen-Robinson T, Shaw JE, et al. Does intentional weight loss improve daytime sleepiness? A systematic review and meta- analysis. Obes Rev. 2017 Apr;18(4):460-75.
• 101 Thomasouli MA, Brady EM, Davies MJ, Hall AP, Khunti K, Morris DH, et al. The impact of diet and lifestyle management strategies for obstructive sleep apnoea in adults: a systematic review and meta-analysis of randomised controlled trials. Sleep Breath. 2013 Sep;17(3):925-35.
• 102 Chirinos JA, Gurubhagavatula I, Teff K, Rader DJ, Wadden TA, Townsend R, et al. CPAP, weight loss, or both for obstructive sleep apnea. N Engl J Med. 2014 Jun;370(24):2265-75.
• 103 Abed HS, Wittert GA, Leong DP, Shirazi MG, Bahrami B, Middeldorp ME, et al. Effect of weight reduction and cardiometabolic risk factor management on symptom burden and severity in patients with atrial fibrillation: a randomized clinical trial. JAMA. 2013 Nov;310(19):2050-60.
• 104 Pathak RK, Middeldorp ME, Meredith M, Mehta AB, Mahajan R, Wong CX, et al. Long-term effect of goal-directed weight management in an atrial fibrillation cohort: a long-term follow-up study (LEGACY). J Am Coll Cardiol. 2015 May;65(20):2159-69.
• 105 Doherty LS, Kiely JL, Swan V, McNicholas WT. Long-term effects of nasal continuous positive airway pressure therapy on cardiovascular outcomes in sleep apnea syndrome. Chest. 2005 Jun;127(6):2076-84.
• 106 Andrén A, Hedberg P, Walker-Engström ML, Wahlén P, Tegelberg A. Effects of treatment with oral appliance on 24-h blood pressure in patients with obstructive sleep apnea and hypertension: a randomized clinical trial. Sleep Breath. 2013 May;17(2):705-12.
• 107 Gotsopoulos H, Kelly JJ, Cistulli PA. Oral appliance therapy reduces blood pressure in obstructive sleep apnea: a randomized, controlled trial. Sleep. 2004 Aug;27(5):934-41.
• 108 Trzepizur W, Gagnadoux F, Abraham P, Rousseau P, Meslier N, Saumet J, et al. Microvascular endothelial function in obstructive sleep apnea: Impact of continuous positive airway pressure and mandibular advancement. Sleep Med. 2009 Aug;10(7):746-52.
• 109 Phillips CL, Grunstein RR, Darendeliler MA, Mihailidou AS, Srinivasan VK, Yee BJ, et al. Health outcomes of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnea: a randomized controlled trial. Am J Respir Crit Care Med. 2013 Apr;187(8):879-87.
• 110 Anandam A, Patil M, Akinnusi M, Jaoude P, El-Solh AA. Cardiovascular mortality in obstructive sleep apnoea treated with continuous positive airway pressure or oral appliance: an observational study. Respirology. 2013 Nov;18(8):1184-90.
• 111 Dal-Fabbro C, Garbuio S, D’Almeida V, Cintra FD, Tufik S, Bittencourt L. Mandibular advancement device and CPAP upon cardiovascular parameters in OSA. Sleep Breath. 2014 Dec;18(4):749-59.
• 112 Galic T, Bozic J, Ivkovic N, Gunjaca G, Ticinovic TK, Dogas Z. Effects of mandibular advancement device treatment on arterial stiffness and glucose metabolism in patients with mild to moderate obstructive sleep apnea: a prospective 1 year study. Sleep Breath. 2016;20(1):69-77.
• 113 Barnes M, McEvoy RD, Banks S, Tarquinio N, Murray CG, Vowles N, et al. Efficacy of positive airway pressure and oral appliance in mild to moderate obstructive sleep apnea. Am J Respir Crit Care Med. 2004;170(6):656-64.
• 114 Hoekema A, Voors AA, Wijkstra PJ, Stegenga B, Van Der Hoeven JH, Tol CG, et al. Effects of oral appliances and CPAP on the left ventricle and natriuretic peptides. Int J Cardiol. 2008 Aug;128(2):232-9.
• 115 Halle TR, Oh MS, Collop NA, Quyyumi AA, Bliwise DL, Dedhia RC. Surgical treatment of OSA on cardiovascular outcomes: a systematic review. Chest. 2017 Dec;152(6):1214-29.
• 116 Huang B, Liu H, Scherlag BJ, Sun L, Xing S, Xu J, et al. Atrial fibrillation in obstructive sleep apnea: Neural mechanisms and emerging therapies. Trends Cardiovasc Med. 2020 Feb;31(2):127-32.
• 117 Linz D, Hohl M, Nickel A, Mahfoud F, Wagner M, Ewen M, et al. Effect of renal denervation on neurohumoral activation triggering atrial fibrillation in obstructive sleep apnea. Hypertension. 2013 Oct;62(4):767-74.
• 118 Van Haesendonck G, Dieltjens M, Kastoer C, Shivalkar B, Vrints C, Van De Heyning CM, et al. Cardiovascular benefits of oral appliance therapy in obstructive sleep apnea: a systematic review. J Dent Sleep Med. 2015 Jan;2(1):9-14.
• 119 Hermida RC, Ayala DE, Fernández JR, Mojón A. Sleep-time blood pressure: prognostic value and relevance as a therapeutic target for cardiovascular risk reduction. Chronobiol Int. 2013 Mar;30(1-2):68-86.
• 120 Vries GE, Wijkstra PJ, Houwerzijl EJ, Kerstjen HA, Hoekema A. Cardiovascular effects of oral appliance therapy in obstructive sleep apnea: a systematic review and meta-analysis. Sleep Med Rev. 2018 Aug;40:55-68.