To the Editor,
We read with interest the recent narrative review entitled “Managing comorbid cardiovascular disease (CVD) and sleep apnea with pharmacotherapy” [Citation1]. We congratulate the authors on their comprehensive approach regarding appropriate CVD pharmacotherapy among Obstructive sleep apnea syndrome (OSAS) patients. They have underlined the importance of OSAS as an independent risk factor and as a therapeutic target in terms of the diagnosis and treatment of CVD.
In the last few years, clinicians have addressed the necessity of appropriate OSAS management and its related comorbidities. There has been a growing scientific and clinical interest in the field of CVD in OSAS patients [Citation2]. During apneic events, multiple pathophysiological processes occur, which may increase the risk of CVD [Citation3].
Continuous positive airway pressure (CPAP) combined with conventional pharmacotherapy should be preferred over usual therapy alone for the treatment of CVD in OSAS patients, either for primary or for secondary prevention [Citation2]. An issue which often arises after initiation of CPAP, apart from adherence, is disease monitoring in relation to effectively reducing and/or preventing concomitant CVD. Accumulating data point to an increasing number of biomarkers [Citation4] or well established scores [Citation5], to enable diagnosis of OSAS-related CVD events.
In their review, the authors have addressed the concomitant effect of OSAS in atrial fibrillation (AF), particularly the beneficial role of CPAP [Citation1]. Current recommendations do not suggest that OSAS represents a serious indication for anticoagulation. However, some considerations may be relevant.
Increased platelet activity has been well studied and is now considered to play an important role in the atherothrombotic process [Citation6]. Mean platelet volume (MPV) is a marker of increased platelet activity and is associated with cerebrovascular, coronary, and peripheral arterial disease [Citation7–Citation9]. MPV has been investigated in OSAS and found to be increased along with severity of OSAS [Citation10] and to be reduced after CPAP treatment [Citation11]. The combination of AF with increased MPV indicates a high cardiovascular risk: the addition of OSAS to well established atherothrombotic factors, increases the risk [Citation12,Citation13]. Should then anticoagulants be initiated and could early prevention of CVD events be based solely on the presence of OSAS with markers of atherothrombosis, such as increased platelet activity? If so, should current guidelines include OSAS as an indicator for early initiation of pharmacotherapy related to atherothrombosis? Finally, is MPV the best risk marker of such events?
In conclusion, further research in the field of atherothrombosis in OSAS patients is warranted. Easily accessible markers should be preferred for routine clinical practice. In this context, increased MPV may prove useful as a marker of CVD risk in OSAS patients.
Declaration of interest
P Steiropoulos has been an advisory board member of AstraZeneca, Boehringer Ingelheim, Novartis and Menarini and has participated in sponsored studies by Angelini and Elpen. He has also received speaker’s honoraria from Boehringer Ingelheim, Chiesi, Elpen and Novartis. He has attended conferences sponsored by Boehringer Ingelheim, Elpen, Novartis and Roche. N Papanas has been an advisory board member of AstraZeneca, Boehringer Ingelheim, Merck Sharp Dohme, Novo Nordisk, Pfizer, Takeda and TrigoCare International. He has also participated in sponsored studies by AstraZeneca, Eli Lilly and Company, GlaxoSmithKline, Merck Sharp Dohme, Novo Nordisk, Novartis and Sanofi and has received speaker’s honoraria from AstraZeneca, Boehringer Ingelheim, Eli Lilly and Company, Elpen, Merck Sharp and Dohme, Mylan, Novo Nordisk, Pfizer, Sanofi and Vianex. N Papanas has attended conferences sponsored by TrigoCare International, Eli Lilly, Galenica, Novo Nordisk, Pfizer and Sanofi. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
Reviewer disclosures
A reviewer has given talks and attended conferences sponsored by Merck Sharp & Dohme, AstraZeneca and Libytec.
Additional information
Funding
References
- Wolf J, Narkiewicz K. Managing comorbid cardiovascular disease and sleep apnea with pharmacotherapy. Expert Opin Pharmacother. 2018;1–9.
- Drager LF, McEvoy RD, Barbe F, et al. Sleep apnea and cardiovascular disease: lessons from recent trials and need for team science. Circulation. 2017;136:1840–1850.
- Shamsuzzaman ASM, Gersh BJ, Somers VK. Obstructive sleep apnea: implications for cardiac and vascular disease. JAMA. 2003;290:1906–1914.
- Maeder MT, Mueller C, Schoch OD, et al. Biomarkers of cardiovascular stress in obstructive sleep apnea. Clin Chim Acta. 2016;460:152–163.
- Archontogeorgis K, Voulgaris A, Nena E, et al. Cardiovascular risk assessment in a cohort of newly diagnosed patients with obstructive sleep apnea syndrome. Cardiol Res Pract. 2018;2018:6572785.
- Nording HM, Seizer P, Langer HF. Platelets in inflammation and atherogenesis. Front Immunol. 2015;6:98.
- Park Y, Schoene N, Harris W. Mean platelet volume as an indicator of platelet activation: methodological issues. Platelets. 2002;13:301–306.
- Slavka G, Perkmann T, Haslacher H, et al. Mean platelet volume may represent a predictive parameter for overall vascular mortality and ischemic heart disease. Arterioscler Thromb Vasc Biol. 2011;31:1215–1218.
- Papanas N, Mikhailidis DP, Steiropoulos P. Obstructive sleep apnea and cardiovascular disease: is mean platelet volume one of the links? Anatol J Cardiol. 2016;16:223.
- Nena E, Papanas N, Steiropoulos P, et al. Mean platelet volume and platelet distribution width in non-diabetic subjects with obstructive sleep apnoea syndrome: new indices of severity? Platelets. 2012;23:447–454.
- Varol E, Ozturk O, Yucel H, et al. The effects of continuous positive airway pressure therapy on mean platelet volume in patients with obstructive sleep apnea. Platelets. 2011;22:552–556.
- Gasparyan AY, Ayvazyan L, Mikhailidis DP, et al. Mean platelet volume: a link between thrombosis and inflammation? Curr Pharm Des. 2011;17:47–58.
- Akyüz A, Akkoyun DÇ, Değirmenci H, et al. Atrial fibrillation is associated with increased mean platelet volume and apnea hypopnea index in patients with obstructive sleep apnea. Angiology. 2015;66:525–530.