Editorial
From heart to bad sleep—Lessons for sleep apnoea in times of crisis
Do coração a dormir mal – lições para a apneia do sono em tempos de crise
J. Moutinho dos Santos
Centro de Medicina do Sono do Centro Hospitalar de Coimbra, Coimbra, Portugal
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"tienePdf" => "pt" "tieneTextoCompleto" => "pt" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "1" "paginaFinal" => "2" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Letters to the Editor: Like a rolling stone?" ] ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.C. Winck, A. Morais" "autores" => array:2 [ 0 => array:2 [ "nombre" => "J.C." "apellidos" => "Winck" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Morais" ] ] ] ] ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0873215911001474?idApp=UINPBA00004E" "url" => "/08732159/0000001800000001/v2_201509041308/S0873215911001474/v2_201509041308/pt/main.assets" ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "From heart to bad sleep—Lessons for sleep apnoea in times of crisis" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "3" "paginaFinal" => "4" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "J. Moutinho dos Santos" "autores" => array:1 [ 0 => array:3 [ "nombre" => "J." "apellidos" => "Moutinho dos Santos" "email" => array:1 [ 0 => "josemoutinho@netcabo.pt" ] ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Centro de Medicina do Sono do Centro Hospitalar de Coimbra, Coimbra, Portugal" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Do coração a dormir mal – lições para a apneia do sono em tempos de crise" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Obstructive sleep apnoea syndrome (OSAS) is a largely prevalent disorder characterized by repeated episodes of pharyngeal obstruction that causes oxygen desaturation and sleep fragmentation. Besides the consequences of excessive daytime sleepiness including increased risk of traffic and labour accidents, OSAS has been implicated, with great or less evidence, as an independent risk factor for different cardiovascular diseases as hypertension, stroke, heart failure, arrhythmias, coronary heart disease and myocardial infarction.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The recognition of OSAS as a treatable putative cause of hypertension and the need for screening is present in international recommendations since 2003.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Several studies have found an association between OSAS and coronary artery disease (CAD). In a large prospective longitudinal study in men and women who were free of CAD at baseline and followed for 8.7 years, after adjustment for multiple risk factors, OSAS was positively associated to myocardial infarction, revascularization procedure or death only in men aged <70 years old (adjusted ratio 1.10 [95% CI 1.00, 1.21] per 10-unit increase in apnoea–hypopnea index), but not in older men or in women of any age.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Other studies showed that patients suffering from CAD with an AHI greater than 10 events/hour were more prone to die in 5-year follow-up than patients without OSAS (37.5% vs. 9.3%, respectively) after controlling for age, weight, and smoking.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> On the other hand in patients with CAD that had percutaneous intervention the probability of restenosis, vessel remodelling and cardiac mortality was greater in the presence of OSAS.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> Moreover patients with CAD treated with CPAP had better prognosis than those who were not treated.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8–11</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">So, it appears rational to establish strategies to search for OSAS in patients with a diagnosis of CAD. In this issue of RPP, Areias et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> contribute to this purpose: using a level IV equipment (ApneaLink™, a two-channel device that monitores respiratory flow and O<span class="elsevierStyleInf">2</span> saturation) they were able to detect the presence of OSAS, confirmed by polysomnography, in 43% of patients admitted to ICU for acute coronary syndrome. These results are not much different from other studies using different methodologies, that together point to a much greater prevalence in CAD than the admitted for general population.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,14</span></a> Independently of some issues that need to be clarified, as the better methodology and time of screening, these date reinforce the importance of detecting OSAS in CAD patients.</p><p id="par0015" class="elsevierStylePara elsevierViewall">OSAS is a treatable condition and the first line treatment is ventilation with continuous positive airway pressure (CPAP); the main challenge of this form of treatment is patient adherence. It is known that multiple factors interfere in this matter that involves individual characteristics (including the symptomatic state, e.g. hypersomnolence but also personality profile), education and literacy, iatrogenicity, marital support, health care support or reimbursement policies. In this issue of RPP Mota et al.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> report an interesting finding of insomnia complaints <span class="elsevierStyleItalic">after</span> the initiation of CPAP treatment for OSAS. Despite some caveats of the study, mainly in psychological characterization of these patients or the timing of appearance and the duration of the symptoms, in our knowledge this is the first paper that gives data on a form of adjustment insomnia that, in this study, appeared to be related to tolerance to CPAP pressure. The association of insomnia to OSAS, in some instances, is already known and can be related to the presence of psychological disturbances<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16,17</span></a> or to be a manifestation of OSAS in and of itself. In the latter case we can expect that treating the respiratory problem solves insomnia and, in fact, in the present study by Mota et al., almost half the patients (11/24) with pre-existing insomnia showed resolution of this problem after initiation of CPAP. Nevertheless, is also known that insomnia complaints have a major impact on adherence to treatment<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18,19</span></a> and that a specific approach should be offered to deal with this problem which underline the importance of multidisciplinary to sleep medicine.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In summary, two articles in this issue of RPP<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,15</span></a> express two important factors in OSAS: one is the necessity to screen patients with cardiovascular disease for OSAS in order to treat them and reduce the risk of serious co-morbidities and, second, is the difficulty in resolving specific problems to assure proper treatment adherence.</p><p id="par0025" class="elsevierStylePara elsevierViewall">OSAS has become an important financial burden to the National Health Service costs: the annual expenses for domiciliary respiratory care amount to 55.5 millions euros/year and, according to data from ACSS, OSAS treatment accounts for more than 50% of that cost<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> As is estimated that only 10% of the patients with OSAS in Portugal are diagnosed and treated<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> an exponential increase in costs is foreseeable, particularly if the platform of patient recruitment is widened to include not only patients with “classic” symptoms but also refractory hypertension or CAD as is pointed by the study of Areias et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> In order to reduce the financial impact the Government has published, for public discussion, guidelines in domiciliary respiratory care that attempt to guarantee that OSAS treatment is provided based on specific diagnostic criteria (not difficult) but also assuming that the payment for treatment be assured only if patient is adherent and stipulating a 6-month “experimental period” (sic). Even if the principle is correct – payment conditioned by adherence – there are multiple causes for non-adherence (as, for instance, that showed in the study by Mota et al.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>) that deserve specific treatment approaches and the resolution of which may need longer time frames than the 6-month period admitted in the government proposal. Moreover, if it is true that short-term adherence can predict long-term adherence, difficulties in treatment compliance may arise at any time and for different reasons. In our experience, only 2–3% of patient refuse, definitively, treatment with CPAP; about 20% present other reasons for adherence below the stipulated as effective and these patients are at risk of having their CPAP payment withdrawn, increasing the burden of the disease due to co-morbidities that could be prevented with the treatment. So, the governmental desire to avoid waste in costs should be calibrated to assure that the patient is offered all solutions necessary to improve adherence and this is, frequently, a task for a multidisciplinary health team based in a reference sleep center. In other words, treatment suspension, even in a situation of refusal, should be a medical decision rather than a burocratic one.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the sleep heart health study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E. Shahar" 1 => "C.W. Whitney" 2 => "S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 10 | 18 |
| 2024 October | 36 | 38 | 74 |
| 2024 September | 34 | 24 | 58 |
| 2024 August | 39 | 34 | 73 |
| 2024 July | 34 | 28 | 62 |
| 2024 June | 31 | 19 | 50 |
| 2024 May | 36 | 41 | 77 |
| 2024 April | 31 | 28 | 59 |
| 2024 March | 25 | 21 | 46 |
| 2024 February | 43 | 17 | 60 |
| 2024 January | 30 | 25 | 55 |
| 2023 December | 15 | 23 | 38 |
| 2023 November | 23 | 30 | 53 |
| 2023 October | 16 | 38 | 54 |
| 2023 September | 22 | 33 | 55 |
| 2023 August | 21 | 14 | 35 |
| 2023 July | 23 | 27 | 50 |
| 2023 June | 15 | 11 | 26 |
| 2023 May | 30 | 26 | 56 |
| 2023 April | 16 | 20 | 36 |
| 2023 March | 16 | 26 | 42 |
| 2023 February | 22 | 23 | 45 |
| 2023 January | 19 | 18 | 37 |
| 2022 December | 20 | 18 | 38 |
| 2022 November | 33 | 34 | 67 |
| 2022 October | 34 | 39 | 73 |
| 2022 September | 21 | 27 | 48 |
| 2022 August | 46 | 37 | 83 |
| 2022 July | 23 | 47 | 70 |
| 2022 June | 46 | 24 | 70 |
| 2022 May | 33 | 37 | 70 |
| 2022 April | 25 | 34 | 59 |
| 2022 March | 23 | 37 | 60 |
| 2022 February | 27 | 35 | 62 |
| 2022 January | 20 | 31 | 51 |
| 2021 December | 23 | 40 | 63 |
| 2021 November | 32 | 30 | 62 |
| 2021 October | 28 | 40 | 68 |
| 2021 September | 17 | 27 | 44 |
| 2021 August | 17 | 26 | 43 |
| 2021 July | 26 | 26 | 52 |
| 2021 June | 16 | 19 | 35 |
| 2021 May | 22 | 21 | 43 |
| 2021 April | 40 | 50 | 90 |
| 2021 March | 43 | 12 | 55 |
| 2021 February | 36 | 18 | 54 |
| 2021 January | 22 | 15 | 37 |
| 2020 December | 24 | 11 | 35 |
| 2020 November | 39 | 22 | 61 |
| 2020 October | 23 | 22 | 45 |
| 2020 September | 70 | 25 | 95 |
| 2020 August | 67 | 22 | 89 |
| 2020 July | 85 | 23 | 108 |
| 2020 June | 86 | 17 | 103 |
| 2020 May | 68 | 14 | 82 |
| 2020 April | 47 | 7 | 54 |
| 2020 March | 57 | 14 | 71 |
| 2020 February | 65 | 30 | 95 |
| 2020 January | 77 | 24 | 101 |
| 2019 December | 61 | 11 | 72 |
| 2019 November | 70 | 12 | 82 |
| 2019 October | 61 | 20 | 81 |
| 2019 September | 70 | 19 | 89 |
| 2019 August | 146 | 12 | 158 |
| 2019 July | 147 | 15 | 162 |
| 2019 June | 148 | 9 | 157 |
| 2019 May | 156 | 18 | 174 |
| 2019 April | 131 | 18 | 149 |
| 2019 March | 203 | 13 | 216 |
| 2019 February | 168 | 12 | 180 |
| 2019 January | 206 | 18 | 224 |
| 2018 December | 113 | 7 | 120 |
| 2018 November | 31 | 0 | 31 |
| 2018 October | 44 | 8 | 52 |
| 2018 September | 23 | 8 | 31 |
| 2018 August | 48 | 35 | 83 |
| 2018 July | 51 | 17 | 68 |
| 2018 June | 52 | 15 | 67 |
| 2018 May | 105 | 10 | 115 |
| 2018 April | 87 | 29 | 116 |
| 2018 March | 99 | 19 | 118 |
| 2018 February | 55 | 9 | 64 |
| 2018 January | 37 | 17 | 54 |
| 2017 December | 73 | 14 | 87 |
| 2017 November | 30 | 16 | 46 |
| 2017 October | 33 | 10 | 43 |
| 2017 September | 25 | 13 | 38 |
| 2017 August | 33 | 14 | 47 |
| 2017 July | 17 | 12 | 29 |
| 2017 June | 42 | 22 | 64 |
| 2017 May | 33 | 21 | 54 |
| 2017 April | 19 | 24 | 43 |
| 2017 March | 13 | 3 | 16 |
| 2017 February | 13 | 5 | 18 |
| 2017 January | 14 | 5 | 19 |
| 2016 December | 13 | 9 | 22 |
| 2016 November | 11 | 7 | 18 |
| 2016 October | 13 | 9 | 22 |
| 2016 September | 6 | 4 | 10 |
| 2016 August | 6 | 5 | 11 |
| 2016 July | 3 | 7 | 10 |
| 2016 June | 8 | 3 | 11 |
| 2016 May | 0 | 7 | 7 |
| 2016 April | 8 | 3 | 11 |
| 2016 March | 29 | 13 | 42 |
| 2016 February | 35 | 20 | 55 |
| 2016 January | 20 | 5 | 25 |
| 2015 December | 24 | 7 | 31 |
| 2015 November | 19 | 5 | 24 |
| 2015 October | 15 | 7 | 22 |
| 2015 September | 26 | 8 | 34 |
| 2015 August | 19 | 6 | 25 |
| 2015 July | 29 | 9 | 38 |
| 2015 June | 17 | 5 | 22 |
| 2015 May | 23 | 7 | 30 |
| 2015 April | 50 | 9 | 59 |
| 2015 March | 27 | 7 | 34 |
| 2015 February | 44 | 6 | 50 |
| 2015 January | 57 | 13 | 70 |
| 2014 December | 58 | 14 | 72 |
| 2014 November | 46 | 3 | 49 |
| 2014 October | 51 | 9 | 60 |
| 2014 September | 56 | 7 | 63 |
| 2014 August | 45 | 7 | 52 |
| 2014 July | 57 | 12 | 69 |
| 2014 June | 47 | 5 | 52 |
| 2014 May | 65 | 9 | 74 |
| 2014 April | 54 | 4 | 58 |
| 2014 March | 67 | 13 | 80 |
| 2014 February | 56 | 7 | 63 |
| 2014 January | 62 | 11 | 73 |
| 2013 December | 49 | 8 | 57 |
| 2013 November | 47 | 13 | 60 |
| 2013 October | 54 | 15 | 69 |
| 2013 September | 52 | 14 | 66 |
| 2013 August | 68 | 13 | 81 |
| 2013 July | 89 | 13 | 102 |
| 2013 June | 61 | 10 | 71 |
| 2013 May | 54 | 17 | 71 |
| 2013 April | 48 | 22 | 70 |
| 2013 March | 63 | 12 | 75 |
| 2013 February | 46 | 22 | 68 |
| 2013 January | 42 | 21 | 63 |
| 2012 December | 32 | 13 | 45 |
| 2012 November | 41 | 21 | 62 |
| 2012 October | 13 | 7 | 20 |
| 2012 September | 18 | 9 | 27 |
| 2012 January | 310 | 0 | 310 |
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