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					Accid Anal Prev. 2003 Jul;35(4):613-7.                                      Related Articles, Links

       Sleep debt, sleepiness and accidents among males in the general
       population and male professional drivers.

       Carter N, Ulfberg J, Nystrom B, Edling C.

       Department of Medical Sciences/Occupational and Environmental Medicine,
       University Hospital, SE-751 85, Uppsala, Sweden.

       Men from the general population and male professional lorry and bus drivers were
       surveyed with regard to sleep habits and motor vehicle and other types of accidents. A
       random sample of 4000 men in the general population of Dalarna County in mid-
       Sweden were mailed a questionnaire and served as referents. A total of 1389 male
       professional lorry and bus drivers from this county responded to the same
       questionnaire. A total of 161 of the drivers also underwent a sleep study in their
       homes.The proportion of total accidents was higher among the professional drivers as
       compared with the males in the population, P=0.03. Reports on traffic accidents were
       the same in both groups, but the professional drivers reported more accidents at leisure
       compared with referents, P<0.0001. Accidents of any kind, traffic accidents included,
       among those affected by both snoring and apneas, were not reported more in either of
       the groups. At the sleep study, 17% of those examined received the diagnosis of
       obstructive sleep-apnea syndrome (OSAS).The professional drivers reported
       proportionally more sleep debt than the referents, P<0.001. Among referents, traffic
       accidents at leisure, traffic accidents while commuting and accidents at work increased
       in proportion to sleep debt (P<0.001, 0.006 and 0.002, respectively). The finding that
       self-perceived sleep debt may have an adverse effect on males in the general
       population and male professional drivers concerning accident likelihood should have
       an impact on prevention. These results stress the need to educate the general
       population on the importance of complying with our biological need of sleep.

Scand J Work Environ Health. 2000 Jun;26(3):237-42.                         Related Articles, Links

       Sleep-disordered breathing and occupational accidents.

       Ulfberg J, Carter N, Edling C.

       Department of Medical Sciences/Occupational and Environmental Medicine,
       University Hospital, Uppsala, Sweden.

       OBJECTIVES: The relationship between a common type of sleep disturbance, sleep-
       disordered breathing, and the risk of becoming involved in an occupational accident
       was studied. METHODS: A 10-year retrospective comparison was made of
       occupational injuries reported to the Occupational Injury Statistics Division of the
       Swedish National Board of Occupational Safety and Health. The injury rates for 704
       consecutive patients suffering from sleep-disordered breathing were compared with
       the rates for an employed, age-matched random sample of 580 subjects, drawn from
       the general population. RESULTS: The risk of being involved in an occupational
       accident was about 2-fold among male heavy snorers and increased by 50% among
       men suffering from obstructive sleep apnea syndrome (OSAS). For females the risk
       increased by at least 3-fold among heavy snorers and OSAS patients. Reduced
       vigilance and attention due to sleep-disordered breathing are the proposed mechanisms
       behind the results. CONCLUSION: The early identification and treatment of persons
       suffering from sleep-disordered breathing would not only have positive impact on
       individual health and well-being but also on occupational safety.

Psychiatry Clin Neurosci. 1999 Dec;53(6):677-9.                            Related Articles, Links

       Improvement of subjective work performance among obstructive sleep
       apnea patients after treatment with continuous positive airway pressure.

       Ulfberg J, Jonsson R, Edling C.

       Department of Medical Sciences/Occupational and Environmental Medicine,
       University Hospital, Uppsala, Sweden.

       Obstructive sleep apnea syndrome (OSAS) is a significant problem for some patients
       presenting with snoring and excessive daytime sleepiness. The 'golden standard'
       therapy in OSAS is considered to be nasal continuous positive airway pressure
       (CPAP). The effects of CPAP on work performance in sleep apnoics has not been
       studied previously. One hundred and fifty-two patients with OSAS participated in an
       open label study. The patients were diagnosed as suffering from severe OSAS after
       they underwent overnight polysomnography showing that their apnea indexes were at
       least 20. The participants answered four questions concerning self-perceived work
       performance prior to and after using CPAP during 6 months. There were highly
       statistically significant decreases (P < 0.000001) in work performance difficulties as
       graded by the patient. The results of this study indicate that CPAP treatment improves
       subjective work performance in patients suffering from OSAS.

J Neurol. 1996 Sep;243(9):621-5.                                           Related Articles, Links

       Headache, snoring and sleep apnoea.

       Ulfberg J, Carter N, Talback M, Edling C.

       Sleep Disorders Center, Avesta Hospital, Sweden.

       To evaluate reported headache prevalence among the general population and patients
       suffering from snoring and obstructive sleep apnoea syndrome (OSAS), a cross-
       sectional study was performed among those aged 30-64 years residing in Kopparberg
       county in central Sweden. Consecutive patients referred to the sleep laboratory in the
       catchment area who fulfilled objective diagnostic criteria (snorers = 448, OSAS =
       324) and a random sample of the general population (n = 583) responded to the same
       questionnaire. Patients were selected following sleep apnoea screening with 100%
       specificity for both OSAS and snoring. Responders from the general population were
       divided into snorers or non-snorers on the basis of self-report. To validate the self-
       report question on snoring in the questionnaire, 50 males and 49 females, randomly
       selected from the sample of the general population, underwent sleep apnoea screening
       in their homes. Headache among both men and women was found to be more
       prevalent among heavy snorers and OSAS patients compared with the control group.
       Morning headache, in particular, was at least three times more common among male
       and female heavy snorers and OSAS patients then among the general population.
       Headache in the control group was more common among snorers than non-snorers.
       Among responders, 5% of the general population reported experiencing headache
       often or very often upon awakening. For the heavy snoring and OSAS groups, 18%
       reported experiencing headache often or very often upon awakening. The results
       indicate that headache is common among heavy snorers and OSAS patients regardless
       of gender.

Chest. 1996 Sep;110(3):659-63.                                              Related Articles, Links

       Excessive daytime sleepiness at work and subjective work performance
       in the general population and among heavy snorers and patients with
       obstructive sleep apnea.

       Ulfberg J, Carter N, Talback M, Edling C.

       Department of Internal Medicine, Avesta Hospital, Sweden.

       STUDY OBJECTIVE: To evaluate excessive daytime sleepiness (EDS) at work and
       effects on reported work performance among men in the general population and male
       patients suffering from snoring and obstructive sleep apnea syndrome (OSAS).
       DESIGN AND PARTICIPANTS: A cross-sectional study of Swedish men between
       the ages of 30 and 64 years in the county of Kopparberg, in mid-Sweden. A random
       sample of the general population (n = 285) and consecutive patients referred to a sleep
       laboratory who fulfilled objective diagnostic criteria (snorers = 289, OSAS = 62)
       responded to a questionnaire. Responders from the general population were divided
       into 2 groups, nonsnorers (n = 223) and snorers (n = 62). To validate a question on
       snoring in the questionnaire, 50 men, randomly selected from the sample of the
       general population, underwent sleep apnea screening in their homes. RESULTS: The
       specificity of the questions about snoring was 83% and the sensitivity was 42%. The
       risk ratios for reporting EDS at work were 4-fold for snorers in the general population,
       20-fold for snoring patients, and 40-fold for patients with OSAS as compared with
       nonsnoring men in the general population. Patients with OSAS and snoring patients
       both showed increased ratios on measures of difficulties with concentration, learning
       new tasks, and performing monotonous tasks when compared with nonsnorers.
       CONCLUSION: Snoring and sleep apnea were highly associated with excessive EDS
       at work and subjective work performance problems. The results provide additional
       evidence that snoring is not merely a nuisance.
Eur Respir J. 2006 Mar;27(3):564-70.                                        Related Articles, Links

       Hypertension prevalence in obstructive sleep apnoea and sex: a
       population-based case-control study.

       Hedner J, Bengtsson-Bostrom K, Peker Y, Grote L, Rastam L, Lindblad U.

       Lund University, Dept of Clinical Sciences, Community Medicine, Malmo University
       Hospital, SE 205 02 Malmo, Sweden.

       Obstructive sleep apnoea (OSA) is a recognised risk factor for hypertension (HT). The
       current authors investigated confounders of this association in a sex-balanced
       community-based sample of patients with HT (n = 161) from the Skaraborg
       Hypertension and Diabetes Project (n = 1,149) and normotensive controls (n = 183)
       from an age and sex stratified community-based population sample (n = 1,109). All
       participants underwent ambulatory home polysomnography. Severe OSA (apnoea-
       plus-hypopnoea index (AHI) >/=30 events.h(-1)) was found in 47 and 25% of
       hypertensive and normotensive males, respectively. The corresponding numbers in
       females were 26 and 24%, respectively. The odds ratio (OR) for HT increased across
       AHI tertiles from 1.0 to 2.1 (95% confidence interval: 0.9-4.5) and 1.0 to 3.7 (95% CI:
       1.7-8.2) in males, but not in females where the OR increased from 1.0 to 1.8 (95% CI:
       0.8-3.9) and 1.0 to 1.6 (95% CI: 0.7-3.5). Regression analysis correcting for age, body
       mass index (or waist-hip ratio) and smoking did not eliminate the association between
       OSA and HT in males. The present data suggest that obstructive sleep apnoea is highly
       prevalent in both the general population and in patients with known hypertension. The
       contribution of obstructive sleep apnoea to hypertension risk may be sex dependent
       and higher in males than in females.

Lakartidningen. 2002 Nov 7;99(45):4473-9.                                   Related Articles, Links

       Sleep apnea a risk factor of cardiovascular disease

       Peker Y, Grote L, Kraiczi H, Hedner J.

       Somnlaboratoriet, avdelningen for lungmedicin och allergologi, Sahlgrenska
       Universitetssjukhuset, Goteborg.

       Obstructive sleep apnea (OSA) affects almost one fifth of the male and 10% of the
       female middle-aged population. Only one fifth of subjects with more or less severe
       disorder of breathing report simultaneous daytime sleepiness. There is growing
       research evidence for an independent association between OSA and cardiovascular
       disease (CVD). The suggestion that this link is not only correlative but also causative
       is strongly supported by a series of recent clinical and epidemiological studies. The
       association between OSA and traditionally recognized cardiovascular risk factors
       suggests that OSA may provide an additive and synergistic risk in cases with co-
       existing obesity, insulin resistance, diabetes and/or dyslipidaemia. These recent
       insights advocate better awareness of OSA and potentially also a wider use of
       screening-tools for early identification and treatment of sleep related breathing
       disorders. Moreover, current research within the fields of obesity and cardiovascular
       prevention needs to identify OSA as a study confounder. Continuous intense research
       into pathophysiological mechanisms and therapeutic possibilities of CVD related to
       OSA appears to be an important and potentially rewarding area of disease prevention.

Am J Respir Crit Care Med. 2002 Jul 15;166(2):159-65.                     Related Articles, Links

       Increased incidence of cardiovascular disease in middle-aged men with
       obstructive sleep apnea: a 7-year follow-up.

       Peker Y, Hedner J, Norum J, Kraiczi H, Carlson J.

       Sleep Laboratory, Department of Pulmonary Medicine, Sahlgrenska University
       Hospital, Gothenburg, Sweden.

       The incidence of a cardiovascular disease (CVD) was explored in a consecutive sleep
       clinic cohort of 182 middle-aged men (mean age, 46.8 +/- 9.3; range, 30-69 years in
       1991) with or without obstructive sleep apnea (OSA). All subjects were free of
       hypertension or other CVD, pulmonary disease, diabetes mellitus, psychiatric disorder,
       alcohol dependency, as well as malignancy at baseline. Data were collected via the
       Swedish Hospital Discharge Register covering a 7-year period before December 31,
       1998, as well as questionnaires. Effectiveness of OSA treatment initiated during the
       period as well as age, body mass index (BMI), systolic blood pressure (SBP), diastolic
       blood pressure (DBP) at baseline, and smoking habits were controlled. The incidence
       of at least one CVD was observed in 22 of 60 (36.7%) cases with OSA (overnight
       oxygen desaturations of 30 or more) compared with in 8 of 122 (6.6%) subjects
       without OSA (p < 0.001). In a multiple logistic regression model, significant
       predictors of CVD incidence were OSA at baseline (odds ratio [OR] 4.9; 95%
       confidence interval [CI], 1.8-13.6) and age (OR 23.4; 95% CI, 2.7-197.5) after
       adjustment for BMI, SBP, and DBP at baseline. In the OSA group, CVD incidence
       was observed in 21 of 37 (56.8%) incompletely treated cases compared with in 1 of 15
       (6.7%) efficiently treated subjects (p < 0.001). In a multiple regression analysis,
       efficient treatment was associated with a significant risk reduction for CVD incidence
       (OR 0.1; 95% CI, 0.0-0.7) after adjustment for age and SBP at baseline in the OSA
       subjects. We conclude that the risk of developing CVD is increased in middle-aged
       OSA subjects independently of age, BMI, SBP, DBP, and smoking. Furthermore,
       efficient treatment of OSA reduces the excess CVD risk and may be considered also in
       relatively mild OSA without regard to daytime sleepiness.
J Hypertens. 2001 Nov;19(11):2071-8.                                        Related Articles, Links

       Blood pressure, cardiac structure and severity of obstructive sleep
       apnea in a sleep clinic population.

       Kraiczi H, Peker Y, Caidahl K, Samuelsson A, Hedner J.

       Department of Clinical Pharmacology, Sahlgrenska University Hospital, Gothenburg,

       OBJECTIVES : We investigated whether the severity of obstructive sleep apnea
       (OSA) predicts blood pressure or cardiac left ventricular thickness in a clinical
       population of OSA patients, if adjustments are made for age, gender, use of
       antihypertensive agents, smoking, body mass index, history of coronary artery disease,
       hypercholesterolemia and circulating C-peptide concentrations. DESIGN :
       Relationships in this cross-sectional study were investigated with correlation analysis
       and multiple regression procedures. PATIENTS AND METHODS : Apnea-hypopnea
       index (AHI, polysomnography) and office systolic and diastolic blood pressures (SBP
       and DBP) were measured in 81 subjects referred to a university hospital sleep
       laboratory. Ambulatory blood pressures were recorded during one 24 h cycle. Left
       ventricular (LV) muscle size was quantified as two-dimensionally directed M-mode-
       derived end-diastolic thickness of interventricular septum and posterior chamber wall.
       RESULTS : After adjustment for separate or the entire set of covariates, AHI
       predicted office SBP and DBP as well as daytime ambulatory DBP and night-time
       ambulatory SBP and DBP, but not daytime ambulatory SBP. In contrast, associations
       between AHI and LV muscle thickness reflected complex inter-relationships with
       confounding variables. Smoking and age suppressed, whereas body mass index (BMI)
       and hypertension inflated the relationship between OSA severity and LV muscle
       thickness in this study. CONCLUSIONS : AHI is an independent predictor of several
       measures of blood pressure. OSA severity and LV muscle thickness appear to be
       primarily linked via increased blood pressure.

Am J Respir Crit Care Med. 2000 Jul;162(1):81-6.                            Related Articles, Links

       Respiratory disturbance index: an independent predictor of mortality in
       coronary artery disease.

       Peker Y, Hedner J, Kraiczi H, Loth S.

       Departments of Pulmonary Medicine and Clinical Pharmacology, Sahlgrenska
       University Hospital, Gothenburg, Sweden.

       Cardiovascular mortality was prospectively investigated in consecutive coronary
       artery disease (CAD) patients with versus without obstructive sleep apnea (OSA)
       during a follow-up period of 5 yr. An overnight sleep/ventilatory study was performed
       in patients requiring intensive care (n = 62, mean age 67.6 +/- 10.4 yr, range 44 to 86)
       during a stable condition (New York Heart Association [NYHA] functional class I-II)
       4 to 21 mo after discharge from the hospital. OSA, defined as a respiratory disturbance
       index (RDI) of 10/h or more was found in 19 patients (mean RDI 17.5 +/- 8.3). Three
       OSA subjects who were successfully treated with continuous positive airway pressure
       (CPAP) during the observation period were excluded from the final analysis. There
       was no statistically significant difference (Fisher two-tailed exact test) between the
       OSA and non-OSA patient groups in terms of number of elderly subjects (age >/= 65
       yr), gender, obesity (body mass index [BMI] >/= 30 kg/m(2)), smoking history,
       presence of hypertension, diabetes mellitus, hypercholesterolemia, or history of
       myocardial infarction at the study start. During the follow-up period, cardiovascular
       death occurred in six of 16 OSA patients (37.5%) compared with 4 (9.3%) in the non-
       OSA group (p = 0.018). The univariate predictors of cardiovascular mortality were
       RDI (p = 0.007), OSA (p = 0.014), age at baseline (p = 0.028), hypertension at
       baseline (p = 0.036), history of never-smoking (p = 0.031), and digoxin treatment
       during the follow-up period (p = 0.013). In a Cox multiple conditional regression
       model, RDI remained as an independent predictor of cardiovascular mortality (exp
       beta = 1.13, 95% confidence interval [CI] 1.05 to 1.21, two-sided p < 0.001). We
       conclude that untreated OSA is associated with an increased risk of cardiovascular
       mortality in patients with CAD. Furthermore, it appears appropriate that RDI is taken
       into consideration when evaluating secondary prevention models in CAD.

Eur Respir J. 1999 Jul;14(1):179-84.                                        Related Articles, Links

An independent association between obstructive sleep apnoea and coronary
artery disease.

Peker Y, Kraiczi H, Hedner J, Loth S, Johansson A, Bende M.

Sahlgrenska University Hospital, Dept of Pulmonary Medicine, Gothenburg, Sweden.

Previous studies of sleep and breathing suggest an independent association between coronary
artery disease (CAD) and obstructive sleep apnoea (OSA) in middle-aged males and females.
These studies, however, were criticized because they did not properly adjust for all important
confounding factors. In order to better control for the impact of these confounders, a case-
control study was performed, matching for age, sex and body mass index (BMI), and
additionally adjusting for hypertension, hypercholesterolemia, diabetes mellitus and current
smoking. A consecutive selection of 62 patients (44 males and 18 females, mean age 69 yrs,
range 44-88 yrs) requiring intensive care for angina pectoris or myocardial infarction at the
County Hospital of Skaraborg, Skovde, Sweden, as well as 62 age-, sex- and BMI- matched
control subjects without history or signs of heart disease underwent an overnight
sleep/ventilatory monitoring study. The time interval between discharge from the intensive
care unit and the overnight study ranged between 4 and 21 months. OSA, defined as a
Respiratory Disturbance Index (RDI) of > or =10 x h(-1), was present in 19 CAD patients but
only in eight control subjects (p=0.017). Using a univariate logistic regression analysis,
current smoking (odds ratio (OR) 8.1, 95% confidence interval (CI) 2.2-29.0), diabetes
mellitus (OR 4.2, 95% CI 1.1-16.1) and OSA (OR 3.0, 95% CI 1.2-7.5), but not hypertension
(OR 1.5, 95% CI 0.7-3.2) and hypercholesterolaemia (OR 1.8, 95% CI 0.7-4.1) were
significantly correlated with CAD. In a multiple logistic regression model, current smoking
(OR 9.8, 95% CI 2.6-36.5), diabetes mellitus (OR 4.2, 95% CI 1.1-17.1) and OSA (OR 3.1,
95% CI 1.2-8.3) all remained independently associated with CAD. In summary, these data
suggest a high occurrence of obstructive sleep apnoea in middle-aged and elderly patients
with coronary artery disease requiring intensive care, which should be taken into account
when considering risk factors for coronary artery disease.

Sleep. 1997 Aug;20(8):645-53.                                             Related Articles, Links

       Reduced hospitalization with cardiovascular and pulmonary disease in
       obstructive sleep apnea patients on nasal CPAP treatment.

       Peker Y, Hedner J, Johansson A, Bende M.

       Department of Pulmonary Medicine, Sahlgrenska University Hospital, Goteborg,

       Cardiovascular and pulmonary disease (CVPD) is common in patients with
       obstructive sleep apnea syndrome (OSAS). This retrospective study addressed the
       accumulated in-hospital time during 2 years prior to treatment with nasal continuous
       positive airway pressure (nCPAP) as compared to 2 years after initiating of nCPAP in
       patients with OSAS and CVPD. A cohort representing all patients (n = 88) receiving
       nCPAP during the period 1988-1994 at the Skovde Central Hospital, Skovde, Sweden,
       was studied. Data collection was based on interviews with patients as well as reviews
       of clinic charts. All hospitalizations and diagnostic codes by any type were thereby
       successfully gathered for the whole group. Six patients with confounding serious
       diseases were excluded from the analysis. A CVPD diagnosis (ICD-9, codes 401-435
       and 490-496) was found in 54 out of 82 patients (66%), of whom 36 of 58 were
       nCPAP users (62%) and 18 of 24 were nonusers (75%). In 54 sleep apneics with
       CVPD, 31 were hospitalized acutely under one or more of these diagnostic codes
       during the study period of 4 years. The total number of in-hospital days due to CVPD
       in the nCPAP users (n = 19) before nCPAP prescription was 413 days (median 10,
       range 3-66) compared to 54 days (median 0, range 0-25) after nCPAP (p < 0.0001).
       The corresponding values for the nonuser group (n = 12) was 137 days (median 8.5,
       range 0-42) before and 188 days (median 9.5, range 0-47) after the nCPAP
       prescription (ns). We conclude that nCPAP treatment reduces the need for acute
       hospital admission due to CVPD in patients with OSAS. This reduction of
       concomitant health care consumption should be taken into consideration when
       assessing the cost-benefit evaluation of nCPAP therapy.
Am J Respir Crit Care Med. 2004 Oct 1;170(7):799-803. Epub 2004 Jul 8.     Related Articles, Links

       The influence of active and passive smoking on habitual snoring.

       Franklin KA, Gislason T, Omenaas E, Jogi R, Jensen EJ, Lindberg E,
       Gunnbjornsdottir M, Nystrom L, Laerum BN, Bjornsson E, Toren K, Janson C.

       Department of Respiratory Medicine, University Hospital, SE-901 85 Umea, Sweden.

       The impact of active smoking, passive smoking, and obesity on habitual snoring in the
       population is mainly unknown. We aimed to study the relationship of habitual snoring
       with active and passive tobacco smoking in a population-based sample. A total of
       15,555 of 21,802 (71%) randomly selected men and women aged 25-54 years from
       Iceland, Estonia, Denmark, Norway, and Sweden answered a postal questionnaire.
       Habitual snoring, defined as loud and disturbing snoring at least 3 nights a week, was
       more prevalent among current smokers (24.0%, p < 0.0001) and ex-smokers (20.3%, p
       < 0.0001) than in never-smokers (13.7%). Snoring was also more prevalent in never-
       smokers exposed to passive smoking at home on a daily basis than in never-smokers
       without this exposure (19.8% vs. 13.3%, p < 0.0001). The frequency of habitual
       snoring increased with the amount of tobacco smoked. Active smoking and passive
       smoking were related to snoring, independent of obesity, sex, center, and age. Ever
       smoking accounted for 17.1% of the attributable risk of habitual snoring, obesity
       (body mass index > or = 30 kg/m(2)) for 4.3%, and passive smoking for 2.2%.
       Smoking, both current and ex-smoking, is a major contributor to habitual snoring in
       the general population. Passive smoking is a previously unrecognized risk factor for
       snoring among adults.

Chest. 2003 Jul;124(1):204-11.                                             Related Articles, Links

       Gender differences in symptoms related to sleep apnea in a general
       population and in relation to referral to sleep clinic.

       Larsson LG, Lindberg A, Franklin KA, Lundback B.

       Department of Medicine, Division of Respiratory Medicine and Allergy, Sunderby
       Central Hospital of Norrbotten, Lulea, Sweden.

       STUDY OBJECTIVES: To study the prevalence, risk factors, and gender differences
       in symptoms related to obstructive sleep apnea. A secondary objective was to study
       gender differences in relation to referral to a sleep clinic for sleep investigations.
       DESIGN AND SETTING: A questionnaire study in a representative sample of the
       general population. A second cohort included patients referred for sleep apnea
       investigation between 1991 and 2000 in the same geographic region.
       PARTICIPANTS: A representative sample of 5,424 subjects aged 20 to 69 years
       living in northern Sweden. Responses were obtained from 4,648 subjects (85.7%).
       RESULTS: Of the male respondents, 17.9% stated that snoring was a problem or said
      that they had relatives who were concerned about witnessed sleep apnea, and of the
      female respondents, 7.4%. The prevalence of snoring and witnessed apneas increased
      with age. In men, there was a peak prevalence rate at 55 to 59 years of age, while the
      corresponding figure in women the peak prevalence rate was at 60 to 64 years of age.
      Having snoring as a problem and relatives who were concerned about witnessed sleep
      apnea were independently associated with male gender, age, and current smoking.
      Snoring as a problem also was associated with higher education. Women who snored
      reported significantly more daytime sleepiness than did men who snored. The
      estimated number of subjects aged 20 to 69 years who had snoring as a problem or had
      relatives who were concerned about witnessed sleep apnea in the population was
      21,160. During the previous decade, 3,955 subjects had been referred to sleep
      laboratories, so < 20% of the estimated number of symptomatic subjects in the
      population had been referred during this 10-year period. The referral rate ratio for
      men/women after correction for population and prevalence of symptoms was 1.25:1 (p
      = 0.012). CONCLUSION: Experiencing snoring as a problem or having relatives who
      are concerned about witnessed sleep apnea are common findings in the population.
      However, during the last decade, only about 20% of the subjects with snoring as a
      problem or with relatives who are concerned about witnessed sleep apnea were
      referred to sleep laboratories. Women were significantly underrepresented in sleep
      laboratory referrals, even though women who snored experienced more subjective
      daytime sleepiness than men.

Sleep Med Rev. 2002 Dec;6(6):429-41.                                      Related Articles, Links

      Cerebral haemodynamics in obstructive sleep apnoea and Cheyne-
      Stokes respiration.

      Franklin KA.

      Department of Respiratory Medicine, University Hospital, SE-901 85 Umea, Sweden.

      Obstructive sleep apnoeas are common among stroke patients and, as different from
      central apnoeas, they do not decline during stroke rehabilitation. Cerebral and
      cardiovascular changes display a different pattern during central and obstructive sleep
      apnoeas. The cerebral blood flow velocity according to transcranial Doppler increases
      during an obstructive apnoea and decreases after apnoea termination concomitant with
      changes in arterial pressure. The changes in cerebral circulation during obstructive
      apnoeas could be an immediate effect of rapid changes in blood pressure because
      cerebral autoregulation is overridden. Low cerebral blood flow, low arterial pressure
      and hypoxemia after apnoea termination may predispose to nocturnal cerebral
      ischaemia. The opposite pattern is seen during a central apnoea, with a decrease in
      cerebral blood flow velocity during apnoea and an increase after apnoea termination.
      Changes during obstructive apnoeas are probably hazardous, with adverse
      cardiovascular effects including stroke. This may not be the case during central
      apnoeas, as Cheyne-Stokes respiration with central apnoeas is a result of an underlying
      disorder such as heart failure and stroke and is not a disease entity in itself. It is
      suggested that obstructive sleep apnoea is a risk factor for stroke as it is common
      among stroke victims and cerebral hypoperfusion occurs after an obstructive apnoea.
      The treatment of sleep apnoea should also be taken into account among stroke
      patients. Large cohort studies, treatment studies and further studies of possible
      mechanisms for apnoea-induced stroke are, however, essential in order to evaluate
      whether obstructive sleep apnoea is an independent risk factor for stroke. 2002
      Harcourt Publishers Ltd

Am J Respir Crit Care Med. 2001 Nov 15;164(10 Pt 1):1910-3.                Related Articles, Links

      Sleep-disordered breathing and coronary artery disease: long-term

      Mooe T, Franklin KA, Holmstrom K, Rabben T, Wiklund U.

      Department of Cardiology, Umea University Hospital, Umea, Sweden.

      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
Respiration. 2001;68(3):250-5.                                              Related Articles, Links

       Obstructive sleep apnoea syndrome is common in subjects with chronic
       bronchitis. Report from the Obstructive Lung Disease in Northern
       Sweden studies.

       Larsson LG, Lindberg A, Franklin KA, Lundback B; Obstructive Lung Disease
       in Northern Sweden Studies.

       Department of Medicine, Division of Respiratory Medicine and Allergy, Sunderby
       Central Hospital of Norrbotten, Lulea, Sweden.

       BACKGROUND: In previous studies we have found that subjects with bronchitis
       have a higher prevalence of 'snoring as a problem' than respiratory healthy subjects.
       OBJECTIVES: We aimed to study whether the high prevalence of snoring among
       subjects with bronchitis also represents a high prevalence of obstructive sleep apnoea
       (OSA). METHOD: Subjects in three age groups born 1919-1920, 1934-1935 and
       1949-1950 had been identified as bronchitic in an earlier study (n = 471) and without
       respiratory symptoms (n = 108). Of the 91 subjects reporting snoring to be a problem,
       70 were invited to participate in the study. Sleep investigation was performed in 52 of
       these 70 subjects. RESULTS: 'Snoring as a problem', predicted OSA to a similar
       degree in both bronchitic and respiratory healthy subjects. The estimated prevalence
       for obstructive sleep apnoea with an apnoea/hypopnoea index (AHI) 10 as the cut-off
       point and concomitant daytime symptoms such as daytime sleepiness or liability to
       nodding off during breaks in activity in the daytime, was 5.4% for bronchitic subjects
       and 2.3% for respiratory healthy subjects. Apnoea in addition to snoring predicted
       OSA better than did snoring alone. Age correlated significantly with AHI, and OSA
       was most common in the middle-aged group, 61-62 years old. CONCLUSION: OSA
       is twice as common in subjects with chronic bronchitis as in subjects free of
       pulmonary disease or symptoms. Copyright 2001 S. Karger AG, Basel

Chest. 2000 Jan;117(1):137-41.                                              Related Articles, Links

       Snoring, pregnancy-induced hypertension, and growth retardation of
       the fetus.

       Franklin KA, Holmgren PA, Jonsson F, Poromaa N, Stenlund H, Svanborg E.

       Department of Respiratory Medicine, University Hospital, Umea, Sweden.

       STUDY OBJECTIVE: Our purpose was to study the relationship between snoring and
       pregnancy-induced hypertension and growth retardation of the fetus. DESIGN:
       Retrospective, cross-sectional, consecutive case series. SETTING: The Department of
       Gynecology and Obstetrics, University Hospital, Umea, Sweden. Participants and
       measurements: On the day of delivery, 502 women with singleton pregnancies
      completed a questionnaire about snoring, witnessed sleep apneas, and daytime fatigue.
      Data concerning medical complications were taken from the women's casebooks.
      RESULTS: During the last week of pregnancy, 23% of the women reported snoring
      every night. Only 4% reported snoring before becoming pregnant. Hypertension
      developed in 14% of snoring women, compared with 6% of nonsnorers (p < 0.01).
      Preeclampsia occurred in 10% of snorers, compared with 4% of nonsnorers (p < 0.05).
      An Apgar score < or = 7 was more common in infants born to habitual snorers.
      Growth retardation of the fetus, defined as small for gestational age at birth, had
      occurred in 7.1% of the infants of snoring mothers and 2.6% of the remaining infants
      (p < 0.05). Habitual snoring was independently predictive of hypertension (odds ratio
      [OR], 2.03; p < 0.05) and growth retardation (OR, 3.45; p < 0.01) in a logistic
      regression analysis controlling for weight, age, and smoking. CONCLUSIONS:
      Snoring is common in pregnancy and is a sign of pregnancy-induced hypertension.
      Snoring indicates a risk of growth retardation of the fetus.

Am J Med. 1996 Sep;101(3):251-6.                                             Related Articles, Links

      Sleep-disordered breathing in women: occurrence and association with
      coronary artery disease.

      Mooe T, Rabben T, Wiklund U, Franklin KA, Eriksson P.

      Department of Internal Medicine, Norrland University Hospital, Umea, Sweden.

      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
Chest. 1996 Mar;109(3):659-63.                                            Related Articles, Links

      Sleep-disordered breathing in men with coronary artery disease.

      Mooe T, Rabben T, Wiklund U, Franklin KA, Eriksson P.

      Department of Internal Medicine, Cardiology Section, Norrland University Hospital,
      Umea, Sweden.

      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.

Lancet. 1995 Apr 29;345(8957):1085-7.                                     Related Articles, Links

      Sleep apnoea and nocturnal angina.

      Franklin KA, Nilsson JB, Sahlin C, Naslund U.

      Department of Pulmonary Medicine and Allergology, University Hospital of Northern
      Sweden, Umea.

      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.
Lakartidningen. 2001 Jun 20;98(25):3018-23.                                  Related Articles, Links

       Drowsiness--greater traffic hazard than alcohol. Causes, risks and

       Haraldsson PO, Akerstedt T.

       Institutionen for oron-, nas- och halssjukdomar, Karolinska institutet. per-

       Stress and shortage of sleep may cause daytime somnolence and impaired vigilance at
       the wheel, especially among those suffering from sleep disturbances. According to the
       international consensus meeting in Stockholm in May of 2000 on "The sleepy driver
       and pilot--causes, risks and countermeasures", drowsy driving is an underestimated
       risk factor in official statistics, and as many as 15-30 percent of today's traffic
       accidents are related to drowsiness; thus it is an even greater risk factor than alcohol.
       Drowsy drivers suffer from inattention, impaired concentration and may even fall
       asleep at the wheel. Accidents during dozing result in three times as many fatalities as
       other accidents. There are a number of reasons for habitual drowsiness at the wheel
       aside from sleep deprivation, including rhonchopathy, shift work and jet lag, mental
       depression, insomnia, narcolepsy, endocrinological diseases, periodic limb movement
       disorder, medication, pain-disordered sleep, and heart disease. Among the most active
       drivers, i.e. middle aged men, obstructive sleep apnea syndrome (OSAS) has been
       found to be the most common reason for habitually drowsy driving. OSAS causes a 2-
       3 fold increased risk of traffic accidents, and it impairs simulated driving. Palatoplasty
       as well as nasal CPAP have been shown to improve vigilance and driving performance
       to an extent that the increase in risk is eliminated. Drivers suffering from habitual
       drowsiness and micro-sleep attacks forcing them to take repeated rests are at special
       risk. Even if they are as dangerous as drivers with unlawful blood alcohol levels they
       cannot be caught in a police checkpoint. However they often seek medial advice, and
       properly treated they may often return safely to traffic. If not, there could be a need to
       report them to the authorities so as to limit or prohibit their driving.

Lakartidningen. 2001 Jun 20;98(25):3014-7.                                   Related Articles, Links

       International consensus meeting on fatigue and the risk of traffic
       accidents. The significance of fatigue for transportation safety is

       Akerstedt T, Haraldsson PO.

       Institutet for psykosocial medicin, institutionen for folkhalsovetenskap, Karolinska
       institutet, Stockholm.

       Recently there has been a sizeable increase in research on fatigue and accidents in
       transportation. Therefore a meeting was convened last year to discuss prevalence,
       mechanisms and countermeasures, with the intention to produce an international
       consensus document. It was concluded that official statistics strongly underestimate
       prevalence, and that a reasonable estimate, based on research, lies between 10 and
       20% for accidents on the road, in the air and at sea. The main causes are disturbed
       sleep and work at the circadian low, caused by night work, morning work, sleep/wake
       disorders (including sleep apnea) or social obstacles to sleep. Suggested
       countermeasures include information/education of the public and of transportation
       companies, as well as enforcement of existing work hour regulation. Additional
       countermeasures include strategic use of napping and caffeine, as well as
       implementation of rumble strips and--possibly--electronic devices for drowsiness

J Clin Epidemiol. 1992 Aug;45(8):821-5.                                     Related Articles, Links

       Sleep apnea syndrome symptoms and automobile driving in a general

       Haraldsson PO, Carenfelt C, Tingvall C.

       Department of Ontorhinolaryngology, Karolinska Institute, Stockholm, Sweden.

       Automobile accidents are reported as being overrepresented in those suffering from
       the obstructive sleep apnea syndrome (SAS), evident by snoring, sleep disturbances
       and diurnal hypersomnia. An estimation of the prevalence of these symptoms amongst
       an adult population, predominantly automobile drivers, was assessed by using a one-
       stage questionnaire procedure. From a national random sample of 1214 persons a
       weighted reply rate of 76% was achieved. Snoring, breath cessations, mid-sleep
       awakenings, and diurnal hypersomnia were reported in 24, 3.8, 27 and 9.1%,
       respectively. The maximum prevalence of SAS was estimated as 2.8-5.5% among
       men, aged 30-69 years, depending on definition used. Driving frequency in potential
       sleep apneics was similar to that of the entire population studied. Diurnal
       hypersomnia, considered a consequence of SAS, was reported as an overall 2.2%,
       corresponding to 100,000 automobile drivers in Sweden.

Acta Otolaryngol. 1990 Jul-Aug;110(1-2):136-40.                             Related Articles, Links

       Driving vigilance simulator test.

       Haraldsson PO, Carenfelt C, Laurell H, Tornros J.

       Department of Otorhinolaryngology, Karolinska Hospital, Stockholm, Sweden.

       Drivers suffering from sleepiness at the wheel run the risk of being involved in car
       accidents. To evaluate whether objective data of driving performance can be assessed
       in patients with excessive tendency of falling asleep at the wheel, two test versions of
       a computerized driving program were created to fit an advanced driving simulator. For
       the evaluation 15 male drivers with habitual sleep spells whilst driving were selected
       among patients with the clinical features of the sleep apnoea syndrome. The brake
       reaction time and the deviations from straight road-line were significantly increased
       when compared to the performance of 10 matched controls. Irrespective of test
       version, the driving simulator with the program used was found to be a sensitive
       method to ascertain driving vigilance impairment in quantitative terms. It would also
       be a valuable method to evaluate the efficiency of treatment in selected patients.

ORL J Otorhinolaryngol Relat Spec. 1990;52(1):57-62.                          Related Articles, Links

       Clinical symptoms of sleep apnea syndrome and automobile accidents.

       Haraldsson PO, Carenfelt C, Diderichsen F, Nygren A, Tingvall C.

       Department of Otorhinolaryngology, Karolinska Hospital, Stockholm.

       Patients with clinical features of sleep apnea syndrome (SAS) and self-reported sleep
       spells at the wheel do poorly in simulated monotonous driving. To evaluate whether
       drivers with defined symptoms of SAS (heavy snoring, sleep disturbances and daytime
       sleepiness) compensate in real traffic by careful driving or not, the rate of car
       accidents over a 5-year period was investigated. A questionnaire was addressed to 140
       patients with and 142 controls without symptoms associated to SAS. Seventy-three of
       the patients had a complete triad of SAS-associated symptoms. Fifty-two percent of
       these patients reported habitual sleep spells at the wheel, as opposed to less than one
       percent by the controls. The ratio of drivers being involved in one or more combined-
       car accident was similar for patients and control drivers, but for single-car accidents
       the ratio was about 7 times higher for patients with a complete triad of symptoms of
       SAS compared to controls (p less than 0.001). When corrected for mileage driven, the
       total number of single-car accidents was almost 12 times higher among patients with
       sleep spells whilst driving, compared to controls (p less than 0.001). It is concluded
       that drivers with the clinical features of SAS are at increased risk especially for single-
       car accidents and that the risk seems to vary with the severity of symptoms.

Eur J Cardiovasc Nurs. 2005 Sep;4(3):183-97.                                  Related Articles, Links

       Sleep disturbances in patients with chronic heart failure and their
       holistic consequences-what different care actions can be implemented?

       Brostrom A, Johansson P.

       Department of Medicine and Care, Faculty of Health Sciences, Linkoping University,
       SE-581 85 Linkoping, Sweden.

       BACKGROUND: Sleep disturbances are prevalent among elderly, especially among
       those with chronic heart failure (CHF) and can affect all dimensions of quality of life
       (QOL) negatively. AIM: To describe the most common causes leading to sleep
       disturbances in patients with CHF, their consequences from a holistic perspective and
       different care actions that can be implemented. METHODS: MEDLINE and CINAHL
       databases were searched from 1989 to July 2004. FINDINGS: Sleep disordered
       breathing (SDB), and insomnia were the most common causes for sleep disturbances
       and occurs in 45--82% (SDB) and one-third (insomnia) of all patients with CHF. SDB
       cause a disturbed sleep structure with frequent awakenings, as well as several adverse
       effects on the cardiovascular system causing increased morbidity and mortality.
       Insomnia, caused by anxiety, an unknown life situation in relation to the debut of
       CHF, or symptoms/deteriorations of CHF can lead to negative effects on all aspects of
       QOL, as well as daytime sleepiness. CONCLUSION: The high prevalence of sleep
       disturbances and their holistic consequences should be taken into account when nurses
       asses and plan the care for patients with CHF. Randomized studies with large sample
       sizes evaluating non-pharmacological nursing interventions that improve sleep are

Scand J Prim Health Care. 2005 Dec;23(4):227-32.                            Related Articles, Links

       Cost of heart failure in Swedish primary healthcare.

       Agvall B, Borgquist L, Foldevi M, Dahlstrom U.

       General Practice, Department of Health and Society, Faculty of Health Sciences,
       Ekholmsvagen 7, SE-582 29 Linkoping, Sweden.

       OBJECTIVES: To calculate the cost for patients with heart failure (HF) in a primary
       healthcare setting. DESIGN: Retrospective study of all available patient data during a
       period of one year. SETTING: Two healthcare centers in Linkoping in the
       southeastern region of Sweden, covering a population of 19 400 inhabitants.
       SUBJECTS: A total of 115 patients with a diagnosis of HF. MAIN OUTCOME
       MEASURES: The healthcare costs for patients with HF and the healthcare utilization
       concerning hospital days and visits to doctors and nurses in hospital care and primary
       healthcare. RESULTS: The mean annual cost for a patient with HF was SEK 37 100.
       There were no significant differences in cost between gender, age, New York Heart
       Association functional class, and cardiac function. The distribution of cost was 47%
       for hospital care, 22% for primary healthcare, 18% for medication, 5% for nursing
       home, and 6% for examinations. CONCLUSION: Hospital care accounts for the
       largest cost but the cost in primary healthcare is larger than previously shown. The
       total annual cost for patients with HF in Sweden is in the range of SEK 5.0-6.7 billion
       according to this calculation, which is higher than previously known.
J Hypertens. 2001 Apr;19(4):683-90.                                          Related Articles, Links

       Mean blood pressure, pulse pressure and grade of hypertension in
       untreated hypertensive patients with sleep-related breathing disorder.

       Grote L, Hedner J, Peter JH.

       Sleep Disorders Centre, Department of Pulmonary Medicine, Sahlgrenska University
       Hospital, Gothenburg, Sweden.

       OBJECTIVE: To test the hypothesis that sleep-related breathing disorder (SRBD) is
       associated with increasing severity of cardiovascular risk markers. DESIGN: A cross-
       sectional study of sleep laboratory patients. SETTING: University Hospital Sleep
       Disorders Centre. PATIENTS: We studied 591 patients referred for a sleep study, all
       of them without a history of systemic hypertension. INTERVENTIONS: Clinical
       interview, two unattended sleep studies, and assessment of office blood pressure,
       cholesterol concentration, alcohol and nicotine consumption and daytime blood gases.
       MAIN OUTCOME MEASURE: Post-hoc analysis of different cardiovascular risk
       markers: mean blood pressure, pulse pressure, and the type and grade of systemic
       hypertension. RESULTS: Patients were classified as normotensive (blood pressure <
       140/90 mmHg, n = 228) or hypertensive (blood pressure > or = 140/90 mmHg, n =
       363) according to office blood pressure measurements. Mixed (systolic and diastolic)
       hypertension was the most common type of hypertension (n = 182), followed by
       isolated diastolic hypertension (n = 101), borderline isolated systolic hypertension (n =
       70), and isolated systolic hypertension (n = 10). The frequency of mixed hypertension
       increased with SRBD activity (P < 0.05) and respiratory disturbance index (RDI; the
       number of breathing disorders per hour of estimated sleep time) was increased in those
       with mixed hypertension compared with those with normotension (24.8 compared
       with 15.7; t test: P < 0.01). In hypertensive patients classified as having grades 1 -3 of
       hypertension (n = 265, 80 and 18, respectively), there was a progressive increase in
       RDI (18.9, 27.2 and 30.3, respectively, P < 0.01). Mean blood pressure increased
       significantly with RDI. Pulse pressure increased significantly with age (P < 0.001), but
       was unrelated to the degree of SRBD. CONCLUSION: We conclude that mean blood
       pressure and the severity of hypertension, but not pulse pressure, increase with the
       severity of the SRBD.

Drugs. 2001;61(2):237-51.                                                    Related Articles, Links

       Treatment options for sleep apnoea.

       Grunstein RR, Hedner J, Grote L.

       Centre for Respiratory Failure and Sleep Disorders, Royal Prince Alfred Hospital and
       University of Sydney, Australia.

       Sleep apnoea (SA) is a common sleep disorder affecting 4 to 25% of the adult
       population. The most common form, obstructive SA, is characterised by recurrent
       upper airway obstruction during sleep associated with sleep disruption and
       hypoxaemia. There is increasing evidence that SA leads to impaired vigilance, quality
       of life, driving accidents and probably represents a vascular disease risk factor.
       Currently, the most effective treatments are aimed at increasing upper airway space by
       either air pressure [(continuous positive airway pressure (CPAP)], upper airway
       surgery or oral appliances. CPAP is the main treatment modality for moderate to
       severe SA but noncompliance approaches 50% in clinic populations. A number of
       pharmacological agents have been used in SA but at this stage, none are indicated in
       moderate to severe SA.

J Hypertens. 2000 Jun;18(6):679-85.                                         Related Articles, Links

Sleep-related breathing disorder is an independent risk factor for uncontrolled

Grote L, Hedner J, Peter JH.

Department of Clinical Pharmacology, Sahlgrenska University Hospital, Gothenburg,

OBJECTIVE: To test the hypothesis that sleep-related breathing disorder (SRBD) is
associated with poor blood pressure control in hypertensive patients independent from
confounding factors such as age, body mass index, alcohol, smoking and daytime blood gases.
DESIGN AND METHODS: This cross-sectional study of a sleep laboratory cohort was
carried out at the University Hospital Sleep Disorders Centre, Marburg. The study comprised
599 patients referred for a sleep study, all of them with a documented history of systemic
hypertension and/or previously initiated antihypertensive therapy. Data were obtained from a
clinical interview, two unattended sleep studies and assessment of clinic blood pressure,
cholesterol level, alcohol and nicotine consumption and daytime blood gases. The main
outcome measure was a post hoc analysis of predictors for poor blood pressure control.
RESULTS: Respiratory disturbance index (RDI) was significantly higher in patients with
uncontrolled hypertension (blood pressure > or = 160 and/or 95 mmHg, n = 463) than in those
with controlled hypertension (n = 136) (34.0 +/- 26.8 versus 27.0 +/- 23.5, P < 0.01). The
relative proportion of patients with uncontrolled hypertension increased significantly as
SRBD activity increased (chi2, P< 0.05). Body mass index was the only independent
predictor (P = 0.006) of uncontrolled hypertension in the whole study sample. However, in
the subset of patients aged < or = 50 years, RDI (P= 0.006) and age (P = 0.016) were the only
independent predictors. The probability of uncontrolled hypertension increased by
approximately 2% (B = 0.019, P= 0.006) for each RDI unit. CONCLUSION: SRBD should
be considered, in addition to traditional confounders, as a risk factor for poor blood pressure
control in younger hypertensive patients (< or = 50 years of age).
Circulation. 2003 Jan 7;107(1):68-73.                                     Related Articles, Links

       Effect of nasal continuous positive airway pressure treatment on blood
       pressure in patients with obstructive sleep apnea.

       Becker HF, Jerrentrup A, Ploch T, Grote L, Penzel T, Sullivan CE, Peter JH.

       Department of Respiratory Medicine, Philipps-University Marburg, Marburg,

       BACKGROUND: There is increasing evidence that obstructive sleep apnea (OSA) is
       an independent risk factor for arterial hypertension. Because there are no controlled
       studies showing a substantial effect of nasal continuous positive airway pressure
       (nCPAP) therapy on hypertension in OSA, the impact of treatment on cardiovascular
       sequelae has been questioned altogether. Therefore, we studied the effect of nCPAP
       on arterial hypertension in patients with OSA. METHODS AND RESULTS: Sixty
       consecutive patients with moderate to severe OSA were randomly assigned to either
       effective or subtherapeutic nCPAP for 9 weeks on average. Nocturnal
       polysomnography and continuous noninvasive blood pressure recording for 19 hours
       was performed before and with treatment. Thirty two patients, 16 in each group,
       completed the study. Apneas and hypopneas were reduced by approximately 95% and
       50% in the therapeutic and subtherapeutic groups, respectively. Mean arterial blood
       pressure decreased by 9.9+/-11.4 mm Hg with effective nCPAP treatment, whereas no
       relevant change occurred with subtherapeutic nCPAP (P=0.01). Mean, diastolic, and
       systolic blood pressures all decreased significantly by approximately 10 mm Hg, both
       at night and during the day. CONCLUSIONS: Effective nCPAP treatment in patients
       with moderate to severe OSA leads to a substantial reduction in both day and night
       arterial blood pressure. The fact that a 50% reduction in the apnea-hypopnea index did
       not result in a decrease in blood pressure emphasizes the importance of highly
       effective treatment. The drop in mean blood pressure by 10 mm Hg would be
       predicted to reduce coronary heart disease event risk by 37% and stroke risk by 56%.

Am J Respir Crit Care Med. 1999 Dec;160(6):1875-82.                       Related Articles, Links

       Sleep-related breathing disorder is an independent risk factor for
       systemic hypertension.

       Grote L, Ploch T, Heitmann J, Knaack L, Penzel T, Peter JH.

       Schlafmedizinisches Labor, Medizinische Poliklinik, Universitat Marburg, Marburg,

       The exact influence of sleep-related breathing disorder (SRBD) on blood pressure
       control remains unknown. We investigated the influence of different degrees of SRBD
       on daytime blood pressure and its association to documented hypertension by
       examining 1,190 consecutive patients referred for diagnosis of SRBD. The protocol
      includes clinical interview, physical examination, office blood pressure measurement,
      cholesterol, and blood gas analysis. Unattended home monitoring of nocturnal
      breathing was performed for assessment of SRBD activity (respiratory disturbance
      index [RDI]). RDI was independently and linearly associated with systolic blood
      pressure (unstandardized coefficient [B] = 0.07 +/- 0.03, p = 0.03), diastolic blood
      pressure (B = 0.07 +/- 0.02, p = 0 < 0.001), and heart rate (B = 0.10 +/- 0.02, p <
      0.001) at rest. The relative risk for hypertension (blood pressure >/= 160/95 mm Hg)
      increased with SRBD severity (odds ratio [OR], 4.15 for RDI >/= 40 versus < 5 [95%
      CI, 2.7 to 6.5]). This relative risk was also elevated in younger (</= 50 yr) compared
      with older patients (> 50 yr) (OR, 7.15 versus 2.70 for RDI >/= 40 versus < 5). These
      cross-sectional clinical data suggest a relationship between SRBD severity and
      systolic blood pressure, diastolic blood pressure, and heart rate after control for
      confounders such as body mass index (BMI), age, alcohol/nicotine consumption,
      cholesterol level, and daytime PO(2) and PCO(2). SRBD is an independent risk factor
      for systemic hypertension with an increased likelihood in subjects </= 50 yr of age.

Sleep Med. 2003 Nov;4(6):531-6.                                           Related Articles, Links

      Snoring and the metabolic syndrome in women.

      Leineweber C, Kecklund G, Akerstedt T, Janszky I, Orth-Gomer K.

      Karolinska Institute, Department of Public Health Sciences, Box 220, 171 77
      Stockholm, Sweden.

      OBJECTIVE: The main objective was to examine the association between metabolic
      syndrome, snoring and sleep quality among women. METHODS: The study sample
      comprised healthy women (30-65 years) from the greater Stockholm area. Snoring and
      sleep quality were measured by the Karolinska Sleep Questionnaire. The metabolic
      syndrome was defined as the presence of two or more of the following components:
      (1) fasting serum glucose level > or =7.0 mmol/L; (2) arterial blood pressure > or
      =140/90 mmHg; (3) fasting serum triglycerides > or =1.7 mmol/L and/or HDL
      cholesterol <1.05 mmol/L; and (4) obesity (waist-to-hip ratio >0.85 and/or BMI > or
      =28 kg/m2). RESULTS: After adjustment for age, the risk ratio of metabolic
      syndrome among snorers as compared to non-snorers was 4.50 (95% CI: 1.71-11.86;
      p=0.002). This association persisted after controlling for menopausal status,
      educational level, smoking, fatigue and exercise habits. Poor sleep quality showed a
      trend (OR: 3.31; 95% CI: 0.89-12.21; p=0.073) towards an increased risk for
      metabolic syndrome, but this did not reach statistical significance. CONCLUSIONS:
      Snoring may be a strong predictor for metabolic syndrome in middle-aged women.
      These findings show that snoring women are not only at increased risk for individual
      risk factors associated with cardiovascular disease and type 2 diabetes, but also for
      metabolic syndrome.