Valeria Bisogni
Giuseppe Maiolino
Martino F. Pengo3,4†- 1Unit of Internal Medicine, Terni University Hospital, Terni, Italy
- 2Clinica Medica 3, Department of Medicine – DIMED, University of Padua, Padua, Italy
- 3Department of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy
- 4Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
Editorial on the Research Topic
Sleep disorders, hypertension and cardiovascular diseases
Clinical studies on ambulatory blood pressure (BP) have shown that increases in BP values, particularly at nighttime, are associated with cardiovascular (CV) morbidity and mortality (1, 2). Accordingly, sleep-related disorders that induce rises in nighttime BP can contribute to further increase CV risk (3–5). The underlying mechanisms supporting this association include sympathetic nervous system activation, oxidative stress, systemic inflammation, endothelial dysfunction, and renin-angiotensin-aldosterone activation. Most of them have been demonstrated in both animal and human studies particularly for sleep-disordered breathing (SDB) such as obstructive sleep apnoea (OSA) (6).
In this Research Topic, we have included several articles trying to further elucidate the relationship between sleep disorders (particularly OSA), systemic arterial hypertension, and CV disease. OSA is indeed the most common sleep-related disorder and is associated with hypertension and CV comorbidities. It affects 10% of adult females and 20% of males with prevalence that can rise up to 40–90% in specific subgroups like patients with severe obesity (7).
In this regard, in the study by Bock et al. it was hypothesized that central adiposity measured by the waist-to-hip ratio (WHR), which appears to be more closely related to the presence of OSA as compared to the body mass index (BMI) (8), might be superior to BMI when predicting ambulatory overnight oximetry (OXI) results. To this point, they examined clinical and anthropometric factors (BMI, WHR), which predicted abnormal OXI, and the need for subsequent polysomnography in a population of 393 men. The presence of abnormal OXI was high (75%), and the strongest predictor of abnormal OXI was the WHR, followed by BMI, age ≥ 55 yrs, and the presence of snoring. A strong association was observed between WHR and abnormal OXI both in obese and non-obese subjects aged ≥ 55 yrs. An interesting point was raised by the authors: WHR is simple, relatively easy to calculate and interpret with minimal cost instrument capable of predicting CV risk. Accordingly, patients triaged to overnight OXI via WHR measurement may avoid lengthy wait times for inpatient polysomnography, and they could initiate a proper treatment sooner.
The treatment of OSA was discussed in the mini review by Arachchige and Steier. They comprehensively described all possible types of OSA treatment available nowadays, including several non-CPAP strategies, such as hypoglossal nerve stimulation and transcutaneous approaches (9). Nevertheless, OSA treatment remains a challenge, and it is necessary to move away from a “one-size-fits-all” strategy and establish a multidisciplinary approach for each patient.
In the second original research by Imanari et al. it was discussed a particular aspect of SBD treatment: adaptative servo-ventilation (ASV). This device can be used in treating SDB in patients with heart failure (HF) and provide information about their residual respiratory events (10). Therefore, the study purpose was to compare, in patients with HF, the apnea-hypopnea index (AHI), determined by the ASV device AutoSet CS (ASC) and with the AHI calculated by polysomnography (PSG). The results are interesting because there was only a modest correlation between the AHI-PSG and AHI-ASC. A possible explanation raised by the authors is related to the presence of central respiratory events during wakefulness or to the attenuation of flow signal amplitude without either arousal or oxygen desaturation, both of which are often observed in patients with HF. According to these findings, when using ASC devices clinicians should consider this discrepancy during the assessment of residual AHI.
Lastly, in the field of OSA treatment and its CV complications, the study protocol by Tavoian et al. has been designed to assess the effects of 24 weeks of high-resistance inspiratory muscle strength training (IMST) on blood pressure (BP) and vascular function. IMST is performed on a portable hand-held device and entails repeated inspiratory efforts against a resistance. It is a simple and time-efficient breathing exercise consistently reported to reduce systolic BP, sympathetic nervous system activity, and endothelial dysfunction in small, selected groups of healthy and high-risk populations at a short-term follow-up (11). Nevertheless, results for OSA patients are still preliminary and require confirmation in a larger group of patients. Based on this evidence, the authors proposed a single-site, double-blind, randomized clinical trial. The primary aim is to observe at least 15-mmHg reduction of systolic BP in middle-aged and older subjects when high-resistance IMST is performed over longer periods (i.e., >6 months). Interestingly, they will try to clarify the underlying mechanisms driving IMST-induced BP reduction, such as vascular endothelial function, aortic stiffness, and nitric oxide and reactive oxygen species production.
Overall, we think that the “Sleep disorders, hypertension and cardiovascular diseases” Research Topic met its objectives by making a significant contribution to a number of different areas of this field, even though there are still many aspects that need to be resolved and better understood regarding the association between sleep disorders and cardiovascular diseases. We hope that the readers will find this Research Topic inspiring and helpful in both research and clinical management of OSA.
Author contributions
All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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References
1. Sega R, Facchetti R, Bombelli M, Cesana G, Corrao G, Grassi G, et al. Prognostic value of ambulatory and home blood pressures compared with office blood pressure in the general population: follow-up results from the Pressioni Arteriose Monitorate e Loro Associazioni (PAMELA) study. Circulation. (2005) 111:1777–83. doi: 10.1161/01.CIR.0000160923.04524.5B
2. Hermida RC, Crespo JJ, Otero A, Domínguez-Sardiña M, Moyá A, Ríos MT, et al. Asleep blood pressure: significant prognostic marker of vascular risk and therapeutic target for prevention. Eur Heart J. (2018) 39:4159–71. doi: 10.1093/eurheartj/ehy475
3. Thomas SJ, Booth JN, Jaeger BC, Hubbard D, Sakhuja S, Abdalla M, et al. Association of sleep characteristics with nocturnal hypertension and nondipping blood pressure in the cardia study. J Am Heart Assoc. (2020) 9:e015062. doi: 10.1161/JAHA.119.015062
4. Maiolino G, Bisogni V, Soranna D, Pengo MF, Pucci G, Vettor R, et al. Effects of insomnia and restless legs syndrome on sleep arterial blood pressure: a systematic review and meta-analysis. Sleep Med Rev. (2021) 59:101497. doi: 10.1016/j.smrv.2021.101497
5. Wolf J, Hering D, Narkiewicz K. Non-dipping pattern of hypertension and obstructive sleep apnea syndrome. Hypertens Res. (2010) 33:867–71. doi: 10.1038/hr.2010.153
6. Parati G, Lombardi C, Hedner J, Bonsignore MR, Grote L, Tkacova R, et al. Recommendations for the management of patients with obstructive sleep apnoea and hypertension. Eur Respir J. (2013) 41:523–38. doi: 10.1183/09031936.00226711
7. Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol. (2013) 177:1006–14. doi: 10.1093/aje/kws342
8. Degache F, Sforza E, Dauphinot V, Celle S, Garcin A, Collet P, et al. Relation of central fat mass to obstructive sleep apnea in the elderly. Sleep. (2013) 36:501–7. doi: 10.5665/sleep.2532
9. Bisogni V, Pengo MF, De Vito A, Maiolino G, Rossi GP, Moxham J, et al. Electrical stimulation for the treatment of obstructive sleep apnoea: a review of the evidence. Expert Rev Respir Med. (2017) 11:711–20. doi: 10.1080/17476348.2017.1358619
10. Allam JS, Olson EJ, Gay PC, Morgenthaler TI. Efficacy of adaptive servoventilation in treatment of complex and central sleep apnea syndromes. Chest. (2007) 132:1839–46. doi: 10.1378/chest.07-1715
11. Craighead DH, Heinbockel TC, Freeberg KA, Rossman MJ, Jackman RA, Jankowski LR, et al. Time-efficient inspiratory muscle strength training lowers blood pressure and improves endothelial function, no bioavailability, and oxidative stress in midlife/older adults with above-normal blood pressure. J Am Heart Assoc. (2021) 10:e020980. doi: 10.1161/JAHA.121.020980
Keywords: sleep-related disorders, obstructive sleep apnoea, restless legs syndrome, cardiovascular diseases, arterial hypertension
Citation: Bisogni V, Maiolino G and Pengo MF (2022) Editorial: Sleep disorders, hypertension and cardiovascular diseases. Front. Cardiovasc. Med. 9:1110487. doi: 10.3389/fcvm.2022.1110487
Received: 28 November 2022; Accepted: 05 December 2022;
Published: 19 December 2022.
Edited and reviewed by: Guido Iaccarino, University of Naples Federico II, Italy
Copyright © 2022 Bisogni, Maiolino and Pengo. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Valeria Bisogni, 
valeriabisogni86@gmail.com
†These authors have contributed equally to this work