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Correspondence |

Cardiovascular Protection From Severe OSA: The Pickwickian Paradox: Is Bigger Really Better? FREE TO VIEW

Yashasvi Chugh, MD; Robert T. Faillace, MD
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

aJacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY

bDepartment of Clinical Medicine, Albert Einstein College of Medicine, Bronx, NY

cNorth Bronx Healthcare Network, Jacobi Medical Center and North Central Bronx Hospital, Bronx, NY

CORRESPONDENCE TO: Yashasvi Chugh, MD, Jacobi Medical Center, 1400 Pelham Parkway, S Bldg 1, Room 3N21, Bronx, NY 10461-1197


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;150(6):1410-1411. doi:10.1016/j.chest.2016.08.1475
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We would like to congratulate Masa and colleagues (July 2016) for elaborating on a novel concept that highlights the data and potential mechanisms of cardiovascular protection in patients with severe OSA and obesity hypoventilation syndrome. Of interest, the authors found that patients with severe OSA (in the third tertile) had the lowest prevalence of cardiovascular morbidity. However, the ischemic preconditioning hypothesis, as a plausible mechanism, may not be generalizable for all conditions included in their definition of cardiovascular morbidity.

Even though the landmark Sleep Heart Health Study found a reduction in recurrent coronary events in patients with severe OSA, the patient population was free of any cardiovascular disease at the time of enrollment, in contrast to the current study, in which this crucial variable was not taken into consideration, potentially adding to a significant selection bias in the studied population. Further, the Sleep Heart Health Study found OSA severity to be associated with more “incident” heart failure in women but not in men; in contrast, in the current study, it is not clear whether there was a lower “prevalence” or lower “incidence” of heart failure. This may be a major limitation of this study’s findings in determining causality.

The possible selection biases that could explain the greater prevalence of chronic heart failure in patients with mild OSA vs severe OSA (based on tertiles) are: (1) greater prevalence of atrial fibrillation, (2) overall worse baseline left ventricular ejection fractions that may have resulted in a greater proportion of patients coming under medical care, and (3) lower compliance to guideline-based medical therapy for heart failure, resulting in more frequent symptoms and a greater number of patients coming under clinical care, which is a crucial variable because heart failure is a clinical diagnosis.

From a pathophysiological perspective, heart failure continues to be a cause of significant cardiovascular burden in patients with severe OSA/obesity hypoventilation syndrome, and the observations of the current study should be interpreted with caution.

References

Masa J.F. .Corral J. .Romero A. .Caballero C. .et al Protective cardiovascular effect of sleep apnea severity in obesity hypoventilation syndrome. Chest. 2016;150:68-79 [PubMed]journal. [CrossRef] [PubMed]
 
Roca G.Q. .Redline S. .Claggett B. .et al Sex-specific association of sleep apnea severity with subclinical myocardial injury, ventricular hypertrophy, and heart failure risk in a community-dwelling cohort: the Atherosclerosis Risk in Communities–Sleep Heart Health Study. Circulation. 2015;132:1329-1337 [PubMed]journal. [CrossRef] [PubMed]
 
Yancy C.W. .Jessup M. .Bozkurt B. .et al 2013 ACCF/AHA Guideline for the Management of Heart Failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62:e147-e239 [PubMed]journal. [CrossRef] [PubMed]
 

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References

Masa J.F. .Corral J. .Romero A. .Caballero C. .et al Protective cardiovascular effect of sleep apnea severity in obesity hypoventilation syndrome. Chest. 2016;150:68-79 [PubMed]journal. [CrossRef] [PubMed]
 
Roca G.Q. .Redline S. .Claggett B. .et al Sex-specific association of sleep apnea severity with subclinical myocardial injury, ventricular hypertrophy, and heart failure risk in a community-dwelling cohort: the Atherosclerosis Risk in Communities–Sleep Heart Health Study. Circulation. 2015;132:1329-1337 [PubMed]journal. [CrossRef] [PubMed]
 
Yancy C.W. .Jessup M. .Bozkurt B. .et al 2013 ACCF/AHA Guideline for the Management of Heart Failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62:e147-e239 [PubMed]journal. [CrossRef] [PubMed]
 
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