Nikolay Poroyliev’s research while affiliated with Medical University of Sofia and other places

Background Exacerbated heart failure is a condition with a high frequency of hospitalizations and mortality, especially in overweight patients. Screening and treatment for sleep apnea can be helpful in these patients. Purpose To determine the frequency and the phenotypic characteristics and of sleep apnea in patients with overweight and exacerbated heart failure. To assess systolic and diastolic function in patients with obstructive and central sleep apnea. To follow patients for one year and to assess hospitalization and mortality. Methods We conducted a single-centre, prospective cohort study form 120 consecutive patients hospitalized for exacerbation heart failure in the cardiology department. 70 patients meet inclusion criteria – Apnea-Hypopnea index (AHI) > 5, Epworth Sleepiness Scale (ESS) > 6, NTproBNP>900 pg/ml, and Body mass index(BMI) >25. All patients receiving optimal medical treatment. The follow-up period was 1 year. The primary endpoint was death for any reason. Sleep apnea screening was performed with ApneaLinkTM. Echocardiographic assessment of left ventricular ejection fraction (LVEF) and the E/e‘m ratio. Results From 70 with sleep apnea 73% (n=51) has obstructive sleep apnea (OSA) and 27% (n=19) has central sleep apnea (CSA). Detected significant changes in LVEF between the OSA group and CSA group (EF% 49.7±8.5vs43.3±9.6.4;p=0.008). Statistically significant changes there was about E/e’m ratio (E/e’m-17.01±3.7 vs 19.3±2.73; p=0.015) and BMI (BMI-38.2±6.5 vs 32.2±3.6; p<0.001). We found a moderate reverse correlation between the LVEF and the number of central sleep apnea events (r=-0,34;p=0,003). Simple linear regression was used to test if the left ventricular ejection fraction significantly predicted the number of central apnea events. The overall regression was statistically significant (R2 = 0.120, F(1,68) = 9.26, p = .003). It was found that the left ventricular ejection fraction significantly predicted the number of central apnea events (β = -0.06, p = .003). Patients from both groups were followed up regarding first hospitalization for heart failure and mortality over a period of 12 months. First hospitalization in patients with CSA occurs significantly sooner than in patients with OSA. The average number of months without hospitalization for HF in patients with CSA was 6.7 months versus 9.7 months in patients with OSA (Log Rank (Mental-Cox) p=0.012). The OSA group had a median survival of 10.5 months versus 9.3 months in the CSA group (Log Rank (Mental-Cox) p=0.026). Conclusion Sleep apnea is a common comorbidity in patients with exacerbated heart failure and overweight. OSA occurs to a greater extent than CSA. Patients with reduced systolic function are at higher risk of central sleep apneas events. Low LVEF% can be used as a prognostic factor regarding the occurrence of central sleep apnea events. Controlling sleep apnea can reduce patient readmissions and mortality.

Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Medical University - Sofia Background Often accompanying comorbidity in patients with acute heart failure and overweight is sleep disorders. Searching and treatment of sleep apnea will be helpful in these patients. CPAP therapy may improve the prognosis. Purpose To determine the frequency and the phenotypic characteristics and of sleep apnea in patients with overweight and exacerbated heart failure. To add continuous positive airway pressure (CPAP) therapy in patients with obstructive sleep apnea (OSA) and monitor changes in systolic and diastolic function. To assess the survival rate in CPAP therapy group and the control group. Methods 100 consecutive patients hospitalized for exacerbation heart failure in the cardiology department. After the selection, 61 patients meet inclusion criteria – Apnea-Hypopnea index (AHI) > 5, Epworth Sleepiness Scale (ESS) > 6, NTproBNP>900 pg/ml, and Body mass index(BMI) >25. All patients receiving optimal medical treatment. The follow-up period was 2 years. The primary endpoint was death for any reason. Sleep apnea screening was performed with ApneaLinkTM. Echocardiographic assessment of left ventricular ejection fraction (LVEF) and the E/e‘m ratio. Results From 61 with sleep disorders 82% (n=50) has OSA and 18% (n=11) has central sleep apnea (CSA). Detected significant changes in LVEF between the OSA group and CSA group (EF% 49.6±8.5vs41.8±11.4;p=0.013). Also statistical significant changes there was about E/e’m ratio and BMI (BMI-38.5±7.1vs31.9±4.5;p=0.005 and E/e’m-17.1±3.7vs20.9±2.5;p=0.002)(Tab. 1). We found a strong reverse correlation between the LVEF and the number of central sleep apnea events (r=-0,52;p<0,001). There was a strong correlation between BMI and ESS (r=0,649;p<0,001). In the OSA group, CPAP therapy was started in 13 patients, the rest of the group (n=37) continue on optimal medication therapy. At the end of the follow-up period in statistical analysis were included 11 patients from the CPAP group and 20 patients from the control group. There was improvement about LVEF, ESS and BMI in CPAP group at end of follow-up (EF%-start: 46,82±9,61vs end of study:49,45±8,23;p=0,019, ESS–start 13±2,6vs end of study 5,9 ±1,5;p<0,001, BMI–start: 39,9±5,6vs end of study: 35,9±4,4;p=0,001). There were no significant changes in E/e'm ratio (E/e'm:start 16,3±3,2vs end of study:15±5,1;p=0,327). In the control group, there were no significant changes. Kaplan-Meier analysis confirmed that the CPAP group has a better survival rate than the control group in the follow-up period (Log-Rank p=0.049). Conclusions Obstructive sleep apnea was more common in obese heart failure patients. The left ventricular systolic function is lower in patients with central sleep apnea. Additional CPAP treatment can improved ejection fraction in patients with heart failure and obstructive sleep apnea. There is a positive effect on BMI. Base on ESS, subjective daytime sleepiness was improved. CPAP therapy can improve the survival rate.

Sleep disorders are a common concomitant comorbidity in patients with heart failure. The aims of our study are to determine the incidence and phenotypic characteristics of sleep apnea in overweight patients with exacerbated heart failure and to assess the degree of involvement of systolic and diastolic function impairment in the individual group. From 100 screened patients with heart failure in our department from 2015 to 2017, 61 met the inclusion criteria and participated in the study. 82% (n = 50) of the patients had obstructive sleep apnea (OSA), and 18% (n = 11) had central sleep apnea (CSA). The CSA group had a significantly lower left ventricular ejection fraction (LVEF) than the OSA group (EF% 49.6 ± 8.5 vs 41.8 ± 11.4; p = 0.013). A negative correlation was found between LVEF and the number of central apnea events (r = -0.52; p < 0.001). More frequent hospitalizations for heart failure (HF) and higher mortality rate were found in the CSA group. Screening for sleep apnea in patients with exacerbated heart failure and obesity is necessary for the complex treatment of these patients.

Objective Arterial stiffness is an independent risk factor in arterial hypertension, but little is known about the association between left atrial remodeling and arterial stiffness in middle – aged hypertensive patients. AIM To investigate the early changes in left atrial (LA) mechanical function and parameters of arterial stiffness in a population of asymptomatic hypertensive individuals. Design and method A total 95 patients (57 ± 14 years) with hypertension, were separated in two groups: 22 patients with normal EA/Ees ratio (Arterial elastance (AE) and ventricular elastance (Ees))and 73 hypertensive patients with decrease EA/Ees ratio, marker for ventriculo – arterial coupling (VAC). All patients underwent standard two - dimentional echocardiography with Speckle tracking analysis for LA – reservoir (LARs), conduit (LAScd) and contractile (LASct) strain. End – systolic pressure was determined from the brachial pulse wave. Arterial elastance (AE) and ventricular elastance (Ees) were calculated as and – systolic pressure/stroke volume and end – systolic pressure/end – systolic volume. Parameters for arterial stiffness – 24 - hour central systolic pressure (cSys24 h) and central pulse pressure (cPP24 h) were measured non – invasively with oscillometric method by Mobil-O-graph PWA. Results RESULTS: Statistically significant differences in parameters of vascular stiffness were found in patients with normal VAC in comparison with disturbed EA/Ees: cSys24 h (107.64 ± 9.19 vs. 116.64 ± 16.7 mm Hg, p = 0.02), cPP24 h (40.23 ± 11.84 vs. 48.08 ± 10.51 mm Hg, p = 0.04). There were statistically significant differences in echocardiography parameters between patients with disturbed VAC in comparison to other group: LAScd (16.86 ± 1.94 vs. 19.49 ± 1.35 %, p < 0.001), LASr (30.22 ± 3.26 vs. 31.81 ± 5.32 %, p = 0.007) and LAVI (30.95 ± 9.22 vs. 36.65 ± 8.83 ml/m ² , p = 0.007). There was positive correlation between LAScd with EA/Ees (r = 0.272, p < 0.008) and negative E/Em (r = -0.264, p < 0.01). LAVI correlated moderate positively with E/Em ratio (r = 0.407, p < 0.0001) and negatively with LAScd (r = - 0.410, p < 0.0001). Conclusions LA mechanical deformation is dependent to arterial stiffness. Reduced LAScd could play a key role in early stages of atrial remodeling. These findings could be used for the prediction of cardiovascular events in this population.

Implementation of new biochemical markers of acute coronary syndrome (ACS) could be helpful in early diagnosis, monitoring and risk stratification in addition to standard risk models. The purpose of our study is to determine the role of high sensitivity C-reactive protein (hsCRP), soluble CD40 Ligand (sCD40L) and endothelial dysfunction in patients with acute coronary syn-drome (ACS). We examined 40 patients divided into three groups: 20 patients with ACS (67:20±12:34 years), 10 patients with risk factors for coronary artery disease (CAD) (62:33±8:67 years) and 10 healthy subjects (51:09±6:75 years). Endothelial function was assessed by peripheral arterial tonometry reactive hy-peremia index (PAT-RHI). The plasma levels of hsCRP and CD40L were mea-sured by ELISA-technique. Patients with ACS and patients with CAD risk factors had higher hsCRP (7:30 ± 3:08 and 7:04 ± 3:23 vs. 2:83 ± 2:74 μg/ml, p = 0:001) and lower PAT-RHI index (1:50±0:59 and 1:81±0:36 vs. 2:08±0:47, p = 0:024) compared to healthy subjects. There were no statistically significant differences in sCD40L levels between the groups. hsCRP was increased in pa-tients with arterial hypertension (7:22±3:07 vs. 2:83±2:74 μg/ml, p = 0:0001) and in patients with dyslipidemia (7:10±3:12 vs. 4:67±3:68 μg/ml, p = 0:033) compared to patients without these risk factors. sCD40L was higher in patients with dyslipidemia (18:55 ± 3:92 vs. 14:37 ± 5:45 ng/ml, p = 0:008). PAT-RHI was reduced in hypertensive patients (1:59 ± 0:54 vs. 2:02 ± 0:47, p = 0:016) and in patients with diabetes (1:38 ± 0:60 vs. 1:87 ± 0:49, p = 0:014). Assess-ment of PAT-RHI and hsCRP may serve as a useful diagnostic tool for more accurate risk stratification in patients with risk factors for CAD in addition to conventional risk factors.