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Background/objectives: Obesity is the main risk factor for obstructive sleep apnoea, commonly occurring in females who are overweight after menopause. We aimed to study the effect of a palaeolithic diet on sleep apnoea in females with overweight after menopause from the population., Methods: Seventy healthy, non-smoking females with a mean age of 60 years and a mean BMI of 33 kg/m 2 were randomised to a palaeolithic diet or to a control low-fat diet according to Nordic Nutritional Recommendations, for 2 years. The apnoea-hypopnoea index was measured and daytime sleepiness was estimated during the intervention., Results: The mean apnoea-hypopnoea index at baseline was 11.6 (95% CI 8.6-14.5). The mean weight loss was 7.2 kg (95% CI 5.3-9.2 kg) in the palaeolithic diet group and 3.9 kg in the control group (95% CI 1.9-5.9 kg); p < 0.021 for the group difference. The reduction in weight corresponded to a reduction in the apnoea-hypopnoea index in the palaeolithic diet group (r = 0.38, p = 0.034) but not in the control group (r = 0.08, p = 0.69). The apnoea-hypopnoea index was reduced in the palaeolithic diet group when the weight was reduced by more than 8 kg. Daytime sleepiness according to the Epworth Sleepiness Scale score and the Karolinska Sleepiness Scale score was unaffected by dietary group allocation., Conclusions: A substantial decrease in body weight of 8 kg was needed to achieve a reduction in sleep apnoea in this small trial of women who are overweight after menopause. The palaeolithic diet was more effective for weight reduction than a control low-fat diet and the reduction in sleep apnoea was related to the degree of weight decrement within this diet group., Trial Registration: Clinicaltrials.gov: NCT00692536., (© 2022. The Author(s).)

Rapid eye movement (REM) obstructive sleep apnea might be particularly harmful to the cardiovascular system. We aimed to investigate the association between sleep apnea during REM sleep and signs of atherosclerotic disease in the form of carotid intima thickness in a community-based sample of men and women and possible sex differences in this association. The association between sleep apnea during REM sleep and intima thickness was analysed cross-sectionally in women from the community-based "Sleep and Health in Women" (SHE) study (n = 253) and age- and body mass index (BMI)-matched men from the "Men in Uppsala; a Study of sleep, Apnea and Cardiometabolic Health" (MUSTACHE) study (n = 338). Confounders adjusted for were age, BMI, gender, alcohol, and smoking. All participants underwent a full-night polysomnography, high-resolution ultrasonography of the common carotid artery, anthropometric measurements, blood pressure measurements, and answered questionnaires. There was an association between sleep apnea during REM sleep and thicker carotid intima that remained after adjustment for confounding (adjusted β = 0.008, p = 0.032). The intima was increased by 9.9% in the group with severe sleep apnea during REM sleep, and this association between severe sleep apnea during REM sleep and increased intima thickness remained after adjustment for confounders (adjusted β = 0.043, p = 0.021). More women than men had severe sleep apnea during REM sleep; moreover, in sex-stratified analyses, the association between sleep apnea during REM sleep and intima thickness was found in women but not in men. We conclude that severe REM sleep apnea is independently associated with signs of atherosclerosis. When stratified by sex, the association is seen in women but not in men., (© 2022 The Authors. Journal of Sleep Research published by John Wiley & Sons Ltd on behalf of European Sleep Research Society.)

Background: The prevalence of obstructive sleep apnea is higher in women after menopause. This is suggested to be a result of an altered sex hormone balance but has so far not been confirmed in a population-based study., Objective: To investigate whether serum concentration of estrogens and progesterone are associated with the prevalence of sleep apnea symptoms in middle-aged women of the general population., Methods: We analyzed data from 774 women (40-67 years) from 15 study centers in seven countries participating in the second follow-up of the European Community Respiratory Health Survey (2010-2012). Multiple logistic regression models were fitted with self-reported symptoms of sleep apnea as outcomes and serum concentrations of various estrogens and progesterone as predictors. All analyses were adjusted for relevant covariates including age, BMI, education, study center, smoking habits, and reproductive age., Results: Among all included women, a doubling of serum concentrations of estrone and progesterone was associated with 19% respectively 9% decreased odds of snoring. Among snorers, a doubling of the concentrations of 17β-estradiol, estrone and estrone 3-sulfate was associated with 18%, 23% and 17% decreased odds of breathing irregularly, and a doubling of the progesterone concentration was further associated with 12% decreased odds of waking up suddenly with a chocking sensation. Other evaluated associations were not statistically significant., Conclusions: Middle-aged women with low serum estrogen and progesterone levels are more likely to snore and report symptoms of obstructive sleep apnea., Competing Interests: The authors have declared that no competing interests exist.

An increased prevalence of obstructive sleep apnoea (OSA) has been suggested in patients with ankylosing spondylitis (AS) in a few controlled studies. We aimed to study the prevalence of OSA compared to controls and to investigate if disease-related and non-disease-related factors were determinants of OSA in AS patients. One hundred and fifty-five patients with AS were included in the Backbone study, a cross-sectional study that investigates severity and comorbidities in AS. Controls were recruited from the Swedish CArdioPulmonary bioImage Study. To evaluate OSA, the participants were asked to undergo home sleep-monitoring during one night's sleep. For each AS patient 45-70 years old, four controls were matched for sex, age, weight, and height. OSA was defined as an apnoea-hypopnoea index (AHI) ≥ 5 events/hour. Sixty-three patients with AS were examined with home sleep-monitoring, and 179 controls were matched with 46 patients, 45-70 years. Twenty-two out of 46 (47.8%) patients with AS vs. 91/179 (50.8%) controls had OSA (AHI ≥ 5 events/hour), P = 0.72. No differences in the sleep measurements were noted in AS patients vs. controls. In logistic regression analysis adjusted for age and sex, higher age, higher BMI, and lesser chest expansion were associated with the presence of OSA in the 63 AS patients. In the current study, patients with AS did not have a higher prevalence of OSA compared to matched controls. AS patients with OSA had higher BMI, were older, and had lesser chest expansion because of more severe AS compared to patients without OSA. Key points • Patients with ankylosing spondylitis did not have a higher prevalence of obstructive sleep apnoea versus matched controls. • Patients with ankylosing spondylitis and obstructive sleep apnoea were older and had higher body mass index versus patients without obstructive sleep apnoea. • Patients with ankylosing spondylitis and obstructive sleep apnoea had lesser chest expansion versus patients without obstructive sleep apnoea., (© 2021. The Author(s).)

Purpose: Obstructive sleep apnea (OSA) is associated with obesity and risk for type 2 diabetes. In this community-based study, we thoroughly investigated fatty acid metabolism, incretin response, glucose tolerance, insulin secretion and insulin sensitivity, and autonomic nerve activity in men with or without OSA., Methods: Fifteen men without diabetes but with signs of severe OSA, defined as apnea-hypopnea index (AHI) >30, and 15 age- and BMI-matched men without OSA (AHI < 5) were recruited from a community-based cohort. Assessments included clinical and anthropometric measurements, a 2-h oral glucose tolerance test (OGTT), and autonomic nerve activity using heart rate variability (HRV)., Results: Men with OSA had higher body fat % than BMI-matched men without OSA (p = 0.046) and it was associated with markers of insulin resistance. The area under the curve for nonesterified fatty acids (NEFA) during OGTT was higher in men with OSA (p = 0.021) and fasting NEFA levels were numerically higher (p = 0.097). The plasma glucose at fasting and during OGTT was higher in men with OSA (p < 0.001). Incretin response was similar between groups. Fasting and OGTT-derived indices indicated impaired insulin sensitivity in men with OSA. Compared with men without OSA, Matsuda index (p = 0.068) and Gutt index (p < 0.01) were lower in men with OSA. The HRV measures did not differ between groups., Conclusions: Our study suggests that fatty acid handling, glucose tolerance, and insulin sensitivity are impaired in men with severe OSA. This might partly be explained by the increased body fat percentage.

Background: The pathophysiology of obstruction and swallowing dysfunction in snores and sleep apnea patients remains unclear. Neuropathy and to some extent myopathy have been suggested as contributing causes. Recently we reported an absence and an abnormal isoform of two cytoskeletal proteins, desmin, and dystrophin, in upper airway muscles of healthy humans. These cytoskeletal proteins are considered vital for muscle function. We aimed to investigate for muscle cytoskeletal abnormalities in upper airways and its association with swallowing dysfunction and severity of sleep apnea., Methods: Cytoskeletal proteins desmin and dystrophin were morphologically evaluated in the uvula muscle of 22 patients undergoing soft palate surgery due to snoring and sleep apnea and in 10 healthy controls. The muscles were analysed with immunohistochemical methods, and swallowing function was assessed using videoradiography., Results: Desmin displayed a disorganized pattern in 21 ± 13% of the muscle fibres in patients, while these fibers were not present in controls. Muscle fibres lacking desmin were present in both patients and controls, but the proportion was higher in patients (25 ± 12% vs. 14 ± 7%, p = 0.009). The overall desmin abnormalities were significantly more frequent in patients than in controls (46 ± 18% vs. 14 ± 7%, p < 0.001). In patients, the C-terminus of the dystrophin molecule was absent in 19 ± 18% of the desmin-abnormal muscle fibres. Patients with swallowing dysfunction had 55 ± 10% desmin-abnormal muscle fibres vs. 22 ± 6% in patients without swallowing dysfunction, p = 0.002., Conclusion: Cytoskeletal abnormalities in soft palate muscles most likely contribute to pharyngeal dysfunction in snorers and sleep apnea patients. Plausible causes for the presence of these abnormalities is traumatic snoring vibrations, tissue stretch or muscle overload.

Purpose: Patients with acromegaly have an increased risk of sleep apnea, but reported prevalence rates vary largely. Here we aimed to evaluate the sleep apnea prevalence in a large national cohort of patients with acromegaly, to examine possible risk factors, and to assess the proportion of patients diagnosed with sleep apnea prior to acromegaly diagnosis., Methods: Cross-sectional multicenter study of 259 Swedish patients with acromegaly. At patients' follow-up visits at the endocrine outpatient clinics of all seven university hospitals in Sweden, questionnaires were completed to assess previous sleep apnea diagnosis and treatment, cardiovascular diseases, smoking habits, anthropometric data, and S-IGF-1 levels. Daytime sleepiness was evaluated using the Epworth Sleepiness Scale. Patients suspected to have undiagnosed sleep apnea were referred for sleep apnea investigations., Results: Of the 259 participants, 75 (29%) were diagnosed with sleep apnea before the study start. In 43 (57%) of these patients, sleep apnea had been diagnosed before the diagnosis of acromegaly. After clinical assessment and sleep studies, sleep apnea was diagnosed in an additional 20 patients, yielding a total sleep apnea prevalence of 37%. Higher sleep apnea risk was associated with higher BMI, waist circumference, and index finger circumference. Sleep apnea was more frequent among patients with S-IGF-1 levels in the highest quartile., Conclusion: Sleep apnea is common among patients with acromegaly, and is often diagnosed prior to their acromegaly diagnosis. These results support early screening for sleep apnea in patients with acromegaly and awareness for acromegaly in patients with sleep apnea.

Background: Obstructive sleep apnea is associated with high blood pressure. The magnitude of blood pressure effects from sleep apnea treatment is unclear. We aimed to determine the effect of mandibular advancement device therapy on ambulatory nighttime and daytime blood pressure in women and men with daytime sleepiness and snoring or mild to moderate sleep apnea (apnea-hypopnea index, <30)., Methods and Results: In this 4-month, double-blind, randomized controlled trial comprising 96 untreated patients, 27 women and 58 men, aged 31 to 70 years, completed the study. The active group received individually made adjustable mandibular advancement devices, and the control group was given individually made sham devices, to be used during sleep. Polysomnographic sleep recordings and ambulatory 24-hour blood pressure measurements were performed at baseline and at follow-up. In women with mandibular advancement devices, the mean nighttime systolic blood pressure was 10.8 mm Hg (95% confidence interval, 4.0-17.7 mm Hg; P =0.004) lower than in the women in the sham group, adjusted for baseline blood pressure, age, body mass index, and the apnea-hypopnea index. The mean nighttime adjusted diastolic blood pressure was 6.6 mm Hg (95% confidence interval, 2.7-10.4 mm Hg; P =0.002) lower in the mandibular advancement device group. In men, there were no significant differences in blood pressure at night or during the daytime between the intervention groups., Conclusions: A mandibular advancement device for obstructive sleep apnea reduces nocturnal blood pressure in women., Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00477009., (© 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Background: Women are often underrepresented at sleep clinics evaluating sleep-disordered breathing (SDB). The aim of the present study was to analyze gender differences in sleep apnea diagnosis and treatment in men and women with similar symptoms of SDB., Methods: Respiratory Health in Northern Europe (RHINE) provided information about snoring, excessive daytime sleepiness (EDS), BMI and somatic diseases at baseline (1999-2001) and follow-up (2010-2012) from 4962 men and 5892 women. At follow-up participants were asked whether they had a diagnosis of and/or treatment for sleep apnea., Results: Among those with symptoms of SDB (snoring and EDS), more men than women had been given the diagnosis of sleep apnea (25% vs. 14%, p < 0.001), any treatment (17% vs. 11%, p = 0.05) and CPAP (6% vs. 3%, p = 0.04) at follow-up. Predictors of receiving treatment were age, BMI, SDB symptoms at baseline and weight gain, while female gender was related to a lower probability of receiving treatment (adj. OR 0.3, 95% CI 0.3-0.5). In both genders, the symptoms of SDB increased the risk of developing hypertension (adj OR, 95% CI: 1.5, 1.2-1.8) and diabetes (1.5, 1.05-2.3), independent of age, BMI, smoking and weight gain., Conclusions: Snoring females with daytime sleepiness may be under-diagnosed and under-treated for sleep apnea compared with males, despite running a similar risk of developing hypertension and diabetes., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Sleep apnea is common in patients with atrial fibrillation, but the effect of the cardioversion of atrial fibrillation to sinus rhythm on central and obstructive apneas is mainly unknown. The primary aim of the study was to analyze the association between cardioversion of atrial fibrillation and sleep apneas, to investigate whether obstructive or central sleep apneas are reduced following cardioversion. A secondary objective was to study the effect on sleep quality., Methods: Twenty-three patients with atrial fibrillation were investigated using overnight polysomnography, including esophagus pressure monitoring and ECG, before and after the cardioversion of persistent atrial fibrillation., Results: Obstructive sleep apnea occurred in 17/23 patients (74%), and central sleep apnea in 6/23 patients (26%). Five patients had both obstructive and central sleep apnea. Sinus rhythm at follow-up was achieved in 16 patients. The obstructive apnea-hypopnea index, central apnea-hypopnea index, and the number of patients with obstructive or central sleep apnea did not differ before and after restoration of sinus rhythm. Sleep time, sleep efficiency, time in different sleep stages, and subjective daytime sleepiness were normal and unaffected by cardioversion., Conclusions: Both obstructive and central sleep apneas are highly prevalent in patients with persistent atrial fibrillation. Obstructive sleep apneas are unaffected by the cardioversion of atrial fibrillation to sinus rhythm. The sleep pattern is normal and unaffected by cardioversion in patients with atrial fibrillation., Clinical Trial Registration: Trial number NCT00429884.

Objectives/hypothesis: To evaluate the effect of radiofrequency surgery of the soft palate on daytime sleepiness in snoring men with mild or no sleep apnea., Study Design: Randomized controlled trial., Methods: Thirty-five men were recruited from consecutive patients referred to the Ear, Nose, and Throat Clinic due to snoring and complaints of daytime sleepiness. The inclusion criteria were an apnea-hypopnea index (AHI) of ≤ 15, male gender, and age 18 to 65 years. Patients were randomized to either radiofrequency or sham surgery of the soft palate. All but one chose and received the option of three treatments. All patients participated in a follow-up, including an overnight sleep apnea recording and questionnaires 12 months after the last treatment. The primary outcome was daytime sleepiness measured with the Epworth Sleepiness Scale (ESS) and other questionnaires. Secondary outcomes were effects on the AHI and subjective snoring., Results: Thirty-two of 35 patients-19 of 20 patients in the radiofrequency surgery group and 13 of 15 patients in the sham surgery group-completed the study. No differences between the two groups in relation to the ESS or AHI were found at follow-up., Conclusion: Radiofrequency surgery of the soft palate has no effect on daytime sleepiness, snoring, or apnea frequency in snoring men with mild or no sleep apnea 1 year after surgery., Level of Evidence: 1b. Laryngoscope 124:2422-2426, 2014., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Obstructive sleep apnoea (OSA) is primarily regarded as a male disorder, presenting with snoring, daytime sleepiness and cardiovascular disease. We aimed to determine the frequency of sleep apnoea among females in the general population. We investigated 400 females from a population-based random sample of 10,000 females aged 20-70 yrs. They answered a questionnaire and performed overnight polysomnography. OSA (apnoea/hypopnoea index (AHI) ≥5) was found in 50% (95% CI 45-55%) of females aged 20-70 yrs. Sleep apnoea was related to age, obesity and hypertension, but not to daytime sleepiness. Severe sleep apnoea (AHI ≥30) was present in 14% (95% CI 8.1-21%) of females aged 55-70 yrs and in 31% (95% CI 12-50%) of obese females with a body mass index of ≥30 kg·m(-2) aged 55-70 yrs. Sleep apnoea with daytime sleepiness and sleep apnoea with hypertension were observed as two different phenotypes of OSA. OSA occurs in 50% of females aged 20-70 yrs. 20% of females have moderate and 6% severe sleep apnoea. Sleep apnoea in females is related to age, obesity and hypertension, but not to daytime sleepiness. When searching for sleep apnoea in females, females with hypertension or obesity should be investigated.

Conclusion: No case of death related to surgery in the form of uvulopalatopharyngoplasty, uvulopalatoplasty or nasal surgery for snoring or sleep apnea has been recorded in Sweden among 4876 patients treated between 1997 and 2005. Severe complications of surgery in the peri- and postoperative period, especially in the form of bleedings and infections, were most common after uvulopalatopharyngoplasty, occurring in 3.7%., Objective: To investigate the frequency of serious complications, including death, of surgery for treatment of snoring and sleep apnea., Methods: All Swedish adults who were treated surgically because of snoring or sleep apnea from January 1997 to December 2005 were identified in the National Patient Register. Mortality and serious complications within 30 days from surgery were obtained from the National Cause of Death Register and the National Patient Register., Results: A total of 4876 patients were treated surgically. Uvulopalatopharyngoplasty was performed in 3572 patients, uvulopalatoplasty in 929 patients, and nasal surgery in 375 patients. None of the surgically treated patients died in the peri- and postoperative period. Severe complications, mainly bleedings and infections, were recorded in 37.1 per 1000 patients treated with uvulopalatopharyngoplasty, in 5.6 per 1000 patients after uvulopalatoplasty, and in 8.8 per 1000 patients after nasal surgery.

Background and Aims: The effects of central sleep apnea in Cheyne-Stokes respiration on sleep-related symptoms and quality of life are not very well established. We aimed to investigate whether Cheyne-Stokes respiration is related to health-related quality of life. We also studied the impact on daytime sleepiness and nocturnal dyspnea., Methods: Included were 203 consecutive patients, stabilized following in-hospital treatment for decompensated congestive heart failure. They underwent overnight cardiorespiratory sleep apnea recordings in hospital and answered a set of questions on symptoms and health-related quality of life questionnaires in the form of the Nottingham Health Profile and the Minnesota Living with Heart Failure Questionnaire. After excluding seven patients with predominantly obstructive apneas and 14 with insufficient recordings, 182 patients were included in the final analysis., Results: One third of the patients had an apnea-hypopnea index (AHI) of >30. Falling asleep in front of the television was the only symptom related to (AHI). Nocturnal dyspnea, daytime sleepiness, generic quality of life or disease-specific quality of life were not related to AHI., Conclusions: Cheyne-Stokes respiration was not associated with health-related quality of life, daytime sleepiness or nocturnal dyspnea among patients stabilized following treatment for congestive heart failure.

Objective: To investigate whether subjects with daytime sleepiness who snore or report witnessed sleep apneas drive more than others., Methods: Questions on snoring, witnessed sleep apnea, excessive daytime sleepiness and driving distance per year were included in the Northern Sweden component of the WHO, MONICA study. Invited were 10756 subjects aged 25-79 years, randomly selected from the population register., Results: There were 7905 (73%) subjects, 3858 men and 4047 women who responded to the questionnaire and attended a visit for a physical examination. Habitually snoring men with daytime sleepiness drove a mean of 22566 (95% CI 18550-26582)km a year, which was significantly more than non-snoring men without excessive daytime sleepiness who drove 17751 (95% CI 17076-18427)km a year, p=0.02, after adjustments for age, body mass index, smoking and physical activity. Men reporting witnessed sleep apnea and excessive daytime sleepiness also drove more than their counterparts in adjusted analysis, p=0.01. Women reporting daytime sleepiness and witnessed apnea tended to drive more, while snoring women with daytime sleepiness did not., Conclusions: Men suffering from excessive daytime sleepiness who snore habitually or report witnessed sleep apneas drive significantly more than others.

Increased sympathetic activity during sleep has been suggested as a link between obstructive sleep apnoea syndrome and cardiovascular disease. Heart rate variability (HRV) is a measure of autonomic effect on the heart. Different parameters have been associated with sympathetic and parasympathetic activity. We have studied HRV in different sleep stages and related the HRV-pattern to sleep apnoea in a population-based sample of 387 women. We investigated the HRV-parameters standard deviation of all R-R intervals (SDNN), root of the averaged square of successive differences (RMSSD), low frequency component (LF), high frequency component (HF), ratio of low frequency component to high frequency component LF/HF and VSAI [variation in sympathetic activity between rapid eye movement (REM) and slow wave sleep, defined as LF(REM)-LF(SWS)]. The HRV-parameters were compared with the results of a full-night polysomnography. Hourly incidence of obstructive episodes was used for classifying the subjects into four apnoea-hypopnoea index (AHI)-groups (<5, > or =5 and <15, 15-30 and >30 events). Individual sleep stages were analysed by pooling all recordings. Women with high AHI had higher heart rate and LF/HF ratio. In subjects with AHI >30, LF/HF ratio however dropped to same level as with AHI <5. Subjects with high AHI had low VSAI. Levels of SDNN, LF and LF/HF ratio during REM and light sleep were similar to wakefulness. In slow wave sleep the parameters decreased. In conclusion, moderately increased prevalence of obstructive apnoeas was associated with signs of higher sympathetic activity. High AHI was however associated with a HRV-pattern suggestive of depressed sympathetic drive and lowered ability to increase it during REM.

Background: Gender differences in the relationship of snoring and diabetes mellitus are mainly unknown. We aimed to analyze the relationship between snoring, witnessed sleep apnea and diabetes mellitus and to analyze possible gender related differences in an unselected population., Methods: Questions on snoring and witnessed sleep apneas were included in the Northern Sweden component of the WHO, MONICA study. Invited were 10,756 men and women aged 25-79 years, randomly selected from the population register., Results: There were 7905 (73%) subjects, 4047 women and 3858 men who responded to the questionnaire and attended a visit for a physical examination. Habitual snoring was related to diabetes mellitus in women, with an adjusted odds ratio (OR)=1.58 (95% confidence interval (CI) 1.02-2.44, p=0.041) independent of smoking, age, body mass index and waist circumference. Witnessed sleep apnea was also independently related to diabetes mellitus in women, with an adjusted OR=3.29 (95% CI 1.20-8.32, p=0.012). Neither snoring, nor witnessed sleep apneas were associated with diabetes mellitus among men, except for witnessed sleep apnea in men aged 25-54 years old. They had an adjusted OR=3.84 (95% CI 1.36-10.9, p=0.011) for diabetes mellitus., Conclusions: Snoring and witnessed sleep apneas are related to diabetes mellitus in women. Witnessed sleep apnea is related to diabetes mellitus in men younger than 55 years old.

Objectives: The aim was to investigate the significance of snoring and sleep apnea on daytime symptoms in a population-based sample of women., Method: From the general population, 400 women aged 20 to 70 years were randomly selected, with oversampling of habitually snoring women. The women were investigated using full-night polysomnography and a questionnaire. The apnea-hypopnea index (AHI) was calculated, and women who acknowledged snoring loudly and disturbingly often or very often were considered habitual snorers., Results: Habitual snoring was independently related to excessive daytime sleepiness (odds ratio [OR], 2.28; 95% confidence interval [CI], 1.31 to 3.99), to falling asleep involuntarily during the day (OR, 2.11; 95% CI, 1.06 to 4.21), to waking up unrefreshed (OR, 2.14; 95% CI, 1.30 to 3.52), to daytime fatigue (OR, 2.77; 95% CI, 1.54 to 4.99), and to a dry mouth on awakening (OR, 2.00; 95% CI, 1.22 to 3.27) after adjustment for AHI, age, body mass index (BMI), smoking, total sleep time, percentage of slow-wave sleep, and percentage of rapid eye movement (REM) sleep. An AHI > or = 15/h was only related to a dry mouth on awakening after adjustment for snoring, age, BMI, smoking, total sleep time, percentage of slow-wave sleep, and percentage of REM sleep (OR, 2.24; 95% CI, 1.14 to 4.40). An AHI of 5 to 15/h was not related to any daytime symptom., Conclusions: Excessive daytime sleepiness and daytime fatigue are related to habitual snoring independent of the apnea-hypopnea frequency, age, obesity, smoking, and sleep parameters in a population-based sample of women, but not to the AHI. This indicates that snoring is an independent cause of excess daytime sleepiness and not merely a proxy for sleep apnea.

Background: The effect of sleep apnea on mortality and cardiovascular morbidity is mainly unknown. We aimed to study whether sleep apnea is related to stroke, death, or myocardial infarction in patients with symptomatic coronary artery disease., Methods and Results: A total of 392 men and women with coronary artery disease referred for coronary angiography were examined by use of overnight sleep apnea recordings. Sleep apnea, defined as an apnea-hypopnea index >or=5, was recorded in 54% of the patients. All patients were followed up prospectively for 10 years, and no one was lost to follow-up. Stroke occurred in 47 (12%) of 392 patients during follow-up. Sleep apnea was associated with an increased risk of stroke, with an adjusted hazard ratio of 2.89 (95% confidence interval 1.37 to 6.09, P=0.005), independent of age, body mass index, left ventricular function, diabetes mellitus, gender, intervention, hypertension, atrial fibrillation, a previous stroke or transient ischemic attack, and smoking. Patients with an apnea-hypopnea index of 5 to 15 and patients with an apnea-hypopnea index >or=15 had a 2.44 (95% confidence interval 1.08 to 5.52) and 3.56 (95% confidence interval 1.56 to 8.16) times increased risk of stroke, respectively, than patients without sleep apnea, independent of confounders (P for trend=0.011). Death and myocardial infarction were not related to sleep apnea. Intervention in the form of coronary artery bypass grafting or percutaneous coronary intervention was related to a longer survival but did not affect the incidence of stroke., Conclusions: Sleep apnea is significantly associated with the risk of stroke among patients with coronary artery disease who are being evaluated for coronary intervention.

Background: Snoring is common in pregnancy, but there are only a few studies that have investigated the relationship of snoring and pregnancy complications. We aimed to investigate the relationship of snoring and witnessed sleep apnoeas with pregnancy-induced hypertension., Methods: A questionnaire was administered on the day of delivery to 456 women at the Department of Obstetrics, Hospital Donación F. Santojanni, Buenos Aires, Argentina. Pregnancy complications and blood pressure measurements were recorded from each woman's medical chart., Results: Some 156 (35%) of 447 women with singleton pregnancies who answered the questionnaire, snored at some time during their pregnancy. Snoring was related to pregnancy-induced hypertension and pre-eclampsia combined, with an adjusted odds ratio of 1.82 (95% CI: 1.16-2.84; p <0.01), independent of body mass index before pregnancy, weight gain during pregnancy, neck circumference, smoking, alcohol and age. Witnessed sleep apnoeas were also related to pregnancy-induced hypertensive disease, with an adjusted odds ratio of 8.00 (95% CI: 2.71-23.55; p <0.001). Daytime sleepiness was more prevalent in snoring women., Conclusions: Snoring and witnessed sleep apnoeas are independently related to pregnancy-induced hypertensive disease.

Objectives: Snoring is associated with subclinical pharyngeal swallowing dysfunction, probably owing to vibration trauma to the pharyngeal tissues caused by snoring. Negative intrathoracic pressure during apnoea causes stretching of the velum and pharynx. The aim of this study was to investigate whether patients with severe sleep apnoea have an increased frequency of videoradiographically diagnosed subclinical pharyngeal swallowing dysfunction compared with snoring patients with or without mild sleep apnoea as well as with non-snoring controls., Methods: Eighty consecutive patients referred for sleep apnoea recordings because of snoring were examined. Fourteen of these patients were excluded because they suffered from dysphagia. Fifteen non-snoring, non-dysphagic volunteers served as controls. Videoradiography was performed to examine the oral and pharyngeal swallowing function in patients and controls. Overnight sleep apnoea recordings were used to evaluate the apnoea-hypopnoea index (AHI)., Results: Pharyngeal swallowing dysfunction was observed in 34/66 (52%) of the snoring patients and in 1/15 (7%) of the non-snoring controls. Pharyngeal swallowing dysfunction was observed in 50% of patients with an AHI of >or=30, in 61% of patients with an AHI of 5-29 and in 43% of patients with an AHI of <5. There was no significant difference in the frequency of pharyngeal swallowing dysfunction between snoring patients with different AHIs., Conclusion: Snoring patients run an increased risk of developing subclinical pharyngeal swallowing dysfunction independent of concomitant sleep apnoea.

The evidence linking sleep-disordered breathing to increased mortality and cardiovascular morbidity has been conflicting and inconclusive. We hypothesized that a potential adverse effect of disordered breathing would be more obvious in patients with established vascular disease. In a prospective cohort study 408 patients aged 70 yr or younger with verified coronary disease were followed for a median period of 5.1 yr. An apnea-hypopnea index (AHI) of > or = 10 and an oxygen desaturation index (ODI) of > or = 5 were used as the diagnostic criteria for sleep-disordered breathing. The primary end point was a composite of death, cerebrovascular events, and myocardial infarction. There was a 70% relative increase and a 10.7% absolute increase in the primary composite end point in patients with disordered breathing defined as an ODI of > or = 5 (risk ratio 1.70, 95% confidence interval [CI] 1.15-2.52, p = 0.008). Similarly, patients with an AHI of > or = 10 had a 62% relative increase and a 10.1% absolute increase in the composite endpoint (risk ratio 1.62, 95% CI 1.09-2.41, p = 0.017). An ODI of > or = 5 and an AHI of > or = 10 were both independently associated with cerebrovascular events (hazard ratio 2.62, 95% CI 1.26-5.46, p = 0.01, and hazard ratio 2.98, 95% CI 1.43-6.20, p = 0.004, respectively). We conclude that sleep-disordered breathing in patients with coronary artery disease is associated with a worse long-term prognosis and has an independent association with cerebrovascular events.

The authors have investigated whether treatment of sleep apnoea with nasal continuous positive airway pressure (nCPAP) improves depressive symptoms, personal activities of daily living (ADL), cognitive functioning and delirium in patients that have suffered a stroke. Sixty-three patients consecutively admitted to a stroke rehabilitation unit 2-4 weeks after a stroke, with an apnoea/hypopnoea index > or =15, were randomized to either nCPAP treatment (n=33) or a control group (n=30). Four patients dropped out after randomization. Both groups were assessed at baseline and after 7 and 28 nights using the Montgomery-Asberg Depression Rating Scale (MADRS), Barthel-ADL index, and the Mini-Mental State Examination (MMSE) scale. Compared to the control group, depressive symptoms (MADRS total score) improved in patients randomized to nCPAP treatment (p=0.004). No significant treatment effect was found with regard to delirium, MMSE or Barthel-ADL index. Delirium and low cognitive level (MMSE score) explained poor compliance with nCPAP. Depressive symptoms are reduced through nasal continuous positive airway pressure treatment in patients with severe stroke and sleep apnoea. Compliance with nasal continuous positive airway pressure treatment is a problem in stroke patients, especially when delirium and severe cognitive impairment occur.

Objectives: The incidence of sleep apnea and stroke increases with age. The aim of this study was to investigate the presence of sleep apnea after stroke and its relationship to delirium, depressed mood, cognitive functioning, ability to perform activities of daily living (ADLs), and psychiatric and behavior symptoms., Design: Cross-sectional study., Setting: Geriatric stroke rehabilitation unit., Participants: 133 patients (78 women and 55 men, mean age 77.1 +/- 7.7 years) consecutively admitted to a geriatric stroke rehabilitation unit., Measurements: All patients underwent overnight respiratory sleep recordings at 23 +/- 7 days (range 11 to 41 days) after suffering a stroke. The patients were assessed using the Organic Brain Syndrome Scale, Montgomery-Asberg-Depression-Rating Scale, Mini-Mental State Examination (MMSE), and Barthel-ADL Index. Sleep apnea was defined as an apnea-hypopnea index (AHI) of 10 or more., Results: The median of the AHI for the studied sample (N = 133) was 13 (range 0-79; interquartile range 6-28). Fifty-nine percent fulfilled the criteria for sleep apnea; 52% with first-ever stroke had sleep apnea. More patients with sleep apnea than without were delirious, depressed, or more ADL-dependent. Sleep apnea patients also had a higher frequency of ischemic heart disease and had more often suffered from an earlier cerebral infarction. Multivariate analysis showed that obesity, low ADL scores, ischemic heart disease, and depressed mood were independently associated with sleep apnea. Low ADL scores, apnea-related hypoxemia, body mass index < or = 27, and impaired vision were independently associated with delirium. The presence of sleep apnea was not associated with any specific type of stroke or location of the brain lesion., Conclusions: Sleep apnea is common in stroke patients and is associated with delirium, depressed mood, latency in reaction and in response to verbal stimuli, and impaired ADL ability. We suggest a trial investigating whether delirium, depressed mood, and ADL ability improve with nasal continuous positive airway pressure treatment of sleep apnea in stroke patients.

Total sleep time is important in investigations of obstructive sleep apnoea, since the diagnosis is usually based on the average number of apnoeas per hour of sleep. Sleep estimates instead of exact EEG-recorded total sleep time is often used in the clinical setting. However, an overestimated sleep time would underestimate the degree of the disease and vice versa. The purpose of this study was to investigate the accuracy of subjective sleep time and time-in-bed as sleep estimates. One hundred patients undergoing diagnostic polysomnography for suspected obstructive sleep apnoea were asked to estimate their sleep time in a questionnaire. Seventy-five patients were diagnosed as suffering from obstructive sleep apnoea syndrome. The mean difference between self-scored and EEG-recorded total sleep time was 4 +/- 74 min. However, 30% scored with a difference greater than 1 h. The intra-class correlation coefficient was fair (0.58, CI: 0.43-0.70). Fifty-three patients overestimated their sleep time and 47 patients underestimated it. All but four patients underestimated their number of awakenings (P<0.001). The mean difference between time-in-bed and EEG-recorded total sleep time was 110 +/- 63 min. This difference was significantly larger than the difference between subjective sleep time and EEG-recorded total sleep time (P<0.001). The intra-class correlation coefficient was poor (0.38, CI: 0.20-0.54). Mean AHI was 27 +/- 27 using subjective sleep time and did not change significantly compared with the mean AHI of 25 +/- 21 based on EEG-recorded total sleep time. Mean AHI decreased significantly to 20 +/- 17 (P<0.001) when time-in-bed was used. In conclusion, 'time-in-bed' time is a poor predictor of total sleep time and should not be used when calculating the apnoea-hypopnoea index. Subjective sleep time is better as an approximation, but the individual differences are large.

Study Objective: To evaluate the effect of a mandibular advancement device in patients with supine-dependent sleep apnea and patients with non-supine-dependent sleep apnea., Design: Prospective study., Setting: Department of Respiratory Medicine, University Hospital, Umeå, Sweden., Patients: Twenty-six patients with obstructive sleep apnea., Intervention: Individually fabricated and adjusted mandibular advancement devices., Measurements: Overnight polysomnographic sleep recordings with and without the device. Supine-dependent sleep apnea was defined when the supine apnea-hypopnea index was > or = 10, together with a lateral apnea-hypopnea index of < 10. Non-supine-dependent sleep apnea was considered when the lateral apnea-hypopnea index was > or = 10., Results: In 12 patients with supine-dependent sleep apnea, the device reduced the supine apnea-hypopnea index from a median of 41 (range, 16 to 70) to 5.9 (range, 0.0 to 15) (p < 0.01). In 14 patients with non-supine-dependent sleep apnea, the treatment reduced the supine apnea-hypopnea index from 44 (range, 1.8 to 73) to 21 (range, 6.3 to 60) (p < 0.05) and the lateral apnea-hypopnea index from 21 (range, 12 to 70) to 4.5 (range, 0.0 to 31) (p < 0.01). The odds ratio for a successful apnea reduction to an apnea-hypopnea index of < 10 in both the supine and the lateral positions was 30 for supine-dependent sleep apnea adjusted for age, obesity, mandibular advancement, and mandibular opening (p < 0.01)., Conclusion: Successful apnea reduction with a mandibular advancement device is highly related to supine-dependent sleep apnea.

The aim of the present study was to evaluate whether the outcome of treatment using an intraoral mandibular advancement device in patients with obstructive sleep apnoea is associated with the mandibular morphology. The effects of the device on apnoeas and sleep were evaluated in 32 men with obstructive sleep apnoea in continuous polysomnographic sleep recordings including body position, during one night without the device and one night with it. Mandibular morphology variables were measured on cephalograms. The odds ratio for a supine apnoea-hypopnoea index of below 15 during treatment was 17 for a mandibular plane angle of 38 degrees or below, and 26 for a lower anterior face height of less then 73 mm. The outcome of treatment in the lateral sleep position was unrelated to any mandibular morphology variable. Patients with supine-dependent sleep apnoea defined by a supine apnoea-hypopnoea index of 10 or above and a lateral apnoea-hypopnoea index of below 10 had an odds ratio of 7 to have an orthognathic mandible with an SNB angle of 78 degrees or above. The present study suggests that a successful apnoea reduction using a mandibular advancement device is associated with a normal mandibular plane angle and a small lower anterior face height.

Objective: To evaluate the effects of a mandibular advancement device on apneas and sleep in mild, moderate, and severe obstructive sleep apnea., Design: Prospective study., Subjects: Forty-four of 47 patients included., Intervention: Individually adjusted mandibular advancement devices., Measurements: Polysomnographic sleep recordings for 1 night without the device and 1 night with it, with a median of 1 day and no changes in weight, medication, or sleep position between the recordings., Results: The device reduced the median obstructive apnea-hypopnea index from 11 (range, 7 to 19) to 5 (range, 0 to 17) (p<0.001) in 21 patients with mild sleep apnea, from 27 (range, 20 to 38) to 7 (range, 1 to 19) (p<0.001) in 15 patients with moderate sleep apnea, and from 53 (range, 44 to 66) to 14 (range, 2 to 32) (p<0.05) in 8 patients with severe sleep apnea. The arousal index decreased and the sleep stage patterns improved in all severity groups. Twenty-eight of 44 patients were successfully treated with an obstructive apnea-hypopnea index of below 10 and a subjective reduction in snoring. Nine of 16 patients with treatment failure still reported a reduction in snoring. The success rate correlated inversely to the disease severity (r=-0.41; p<0.01)., Conclusions: A mandibular advancement device reduces apneas and improves sleep quality in patients with obstructive sleep apnea, especially in those with mild and moderate disease. A follow-up sleep recording during treatment is necessary because of the risk of silent obstructive apneas without subjective snoring with the device.

Objective: To examine the effect of oxygen on apneas and sleep quality in patients with frequent central apneas during sleep., Design/subjects: Prospective intervention study of 20 consecutive patients with predominant central apnea identified from 570 patients referred for suspected sleep apnea syndrome. Sixteen patients had congestive heart failure and seven of them had a previous stroke. Three of the remaining four patients without heart failure had experienced a previous stroke, and one was being treated with morphine., Setting: The Department of Pulmonary Medicine at Umeå (Sweden) University Hospital., Interventions: The patients were investigated for one night receiving nasal oxygen and one night without it., Measurements: Overnight polysomnography with transcutaneous PCO2 and arterial blood gases., Results: Central apneas occurred during Cheyne-Stokes respiration in 18 of 20 patients and two patients had idiopathic central apneas. Without oxygen, the median number of all central apneas and hypopneas was 33.5 (range, 8.0 to 52.0) per hour of sleep. These episodes decreased to 5.0 (range, 0.0 to 31.0)(p < 0.01) during oxygen therapy. In 17 of 20 patients, the frequency of central apneas was reduced by more than 50%. Central apneas were reduced by oxygen irrespective of the presence or absence of heart failure or Cheyne-Stokes respiration. The arousal frequency was reduced during oxygen treatment. Daytime sleepiness, difficulty falling asleep, snoring, and self-scored awakenings were reduced in seven patients who were given nocturnal oxygen at home. Obstructive and mixed apneas were unaffected by oxygen., Conclusions: Oxygen effectively reduces central sleep apnea in eucapnic patients.

Purpose: To examine the occurrence of sleep apnea and nocturnal hypoxemia in women with and without coronary artery disease (CAD) and to investigate the relationship between sleep-disordered breathing and coronary artery disease., Patients and Methods: In a case-control study, 102 cases were randomly selected among women with angina pectoris and angiographically verified coronary disease. Fifty age-matched controls without known heart disease were selected from the population registry. Pulse oximetry, oronasal thermistors, body position indicator, and recording of body and respiratory movements were used to quantify oxygen desaturations (the number of desaturations > or = 4% per hour of sleep, oxygen desaturation index [ODI]) and apneas (the number of apneas or hypopneas per hour of sleep, apnea-hypopnea index [AHI])., Results: Women with CAD had a high occurrence of disordered breathing measured as AHI > or = 5, 54% (n = 54), AHI > or = 10, 30% (n = 30) or ODI > or = 5, 34% (n = 35) while the same proportions in controls were 20% (n = 10, P < 0.0001), 10% (n = 5, P < 0.01) and 18% (n = 9, P < 0.05), respectively. In a multiple logistic regression model, sleep apnea (AHI > or = 5), hypertension, and smoking habits were independent predictors of CAD with odds ratios of 4.1 (95% confidence interval [CI] 1.7 to 9.7, P < 0.01), 3.4 (CI 1.3 to 8.9, P < 0.05) and 2.4 (CI 1.0 to 5.7, P < 0.05), respectively., Conclusion: Sleep apnea is common in women with CAD and remains as a significant predictor of coronary disease after adjustment for age, body mass index, hypertension, smoking habits, and diabetes.

Objective: To examine the occurrence of sleep apnea and nocturnal hypoxemia in men with symptomatic coronary artery disease (CAD) and to evaluate the relationship between disordered breathing and coronary artery disease., Design: Case-control study. Cases were randomly selected from men undergoing coronary angiography because of angina pectoris. Controls were age matched and selected from the population registry. Pulse oximetry, oronasal thermistors, body position indicator, and recording of body and respiratory movements were used to quantify desaturations and apneas., Setting: Norrland University Hospital, a referral center for northern Sweden., Subjects: One hundred forty-two men with angina pectoris and angiographically verified CAD and 50 controls without known heart disease., Main Outcome Measures: The number of arterial oxygen desaturations of 4% or more per hour of sleep, oxygen desaturation index (ODI), and the number of apneas or hypopneas per hour of sleep, apnea-hypopnea index (AHI)., Results: Men with CAD had a high occurrence of sleep-disordered breathing measured as ODI of 5 or more, 39% (n=55), or AHI of 10 or more, 37% (n=50), while, the same proportions in controls were 22% (n=11, p<0.05) and 20% (n=10, p<0.05). Mean values of ODI in cases and controls were 6.4 and 2.7, respectively (p<0.001). Multiple logistic regression analysis identified ODI, AHI, body mass index, and hypertension as significant predictors of CAD (p<0.05)., Conclusion: Sleep- disordered breathing is common in men with CAD. A significant association between sleep apnea with nocturnal hypoxemia and CAD remains after adjustment for age, hypertension, body mass index, diabetes, and smoking.

Hypoxaemia occurs with sleep apnoea and might induce nocturnal angina. Sleep apnoea was found in 9 of 10 patients with nocturnal angina pectoris. Nocturnal angina diminished during treatment of sleep apnoea by continuous positive airway-pressure, and the number of nocturnal myocardial ischaemic events measured by computerised vector-cardiography was reduced.

Cerebral circulation was studied in six patients with obstructive sleep apnea (OSA) by transcranial Doppler. Cerebral blood flow velocity (CBFV), pulsatility index (Pi), intra-arterial radial blood pressure, transcutaneous blood gases, and respiration were recorded during sleep with or without apneas. There was a concomitant increase of mean arterial pressure (Pa) and CBFV by 11 +/- 6% (p < 0.001) and 15 +/- 6% (p < 0.001) compared with baseline at 5.1 +/- 2.4 and 5.3 +/- 2.6 s, respectively, after apnea termination. Pa and CBFV decreased to a minimum of -8 +/- 2% (p < 0.001) and -23 +/- 8% (p < 0.001), respectively, below baseline at 19.8 +/- 5.0 and 19.4 +/- 4.5 s after apnea. Values returned to baseline within 60 s, except during repetitive apneas, which were associated with prolonged periods of reduced Pa and CBFV. Pi changed inversely to CBFV and rose to 34 +/- 15% (p < 0.001) above baseline 19.5 +/- 5.5 s after the end of apnea because of a decrease in diastolic CBFV. There was a close correlation between Pa and CBFV (r = 0.67, p < 0.001), indicating that cerebral autoregulation is insufficient to protect the brain from rapid systemic pressure changes in OSA. The findings suggest that apneas during sleep are associated with profound changes in cerebral blood flow. Apnea-induced hypoxemia combined with reduced cerebral perfusion may predispose to nocturnal cerebral ischemia in patients with OSA.