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PubMed2005

Early signs of atherosclerosis in obstructive sleep apnea.

BACKGROUND: Obstructive sleep apnea (OSA) is associated with several cardiovascular diseases. However, the mechanisms are not completely understood. Recent studies have shown that OSA is associated with multiple markers of endothelial damage. We hypothesized that OSA affects functional and structural properties of large arteries, contributing to atherosclerosis progression. METHODS AND MEASUREMENTS: Twelve healthy volunteers, 15 patients with mild to moderate OSA, and 15 with severe OSA matched for age, sex, and body mass index were studied by using (1) full standard overnight polysomnography; (2) carotid-femoral pulse wave velocity with a noninvasive automatic device; and (3) a high-definition echo-tracking device to measure intima-media thickness, diameter, and distensibility. All participants were free of hypertension, diabetes, and smoking, and were not on any medications. Patients with OSA were naive to treatment. MAIN RESULTS: Significant differences existed between control subjects and patients with mild to moderate and severe OSA (apnea-hypopnea index, 3.1 +/- 0.3, 16.2 +/- 1.7, and 55.7 +/- 5.9 events/hour, respectively) in pulse wave velocity (8.7 +/- 0.2, 9.2 +/- 0.2, and 10.3 +/- 0.2 m/second; p < 0.0001), intima-media thickness (604.4 +/- 25.2, 580.2 +/- 29.0, and 722.2 +/- 35.2 microm; p = 0.004), and carotid diameter (6,607.8 +/- 126.7, 7,152.3 +/- 114.4, and 7,539.9 +/- 161.2 microm; p < 0.0001). Multivariate analyses showed that the apnea-hypopnea index correlated independently with pulse wave velocity and intima-media thickness variability (r = 0.61, p < 0.0001, and r = 0.44, p = 0.004, respectively), whereas minimal oxygen saturation correlated with the carotid diameter (r = -0.60, p < 0.0001). CONCLUSIONS: Middle-aged patients with OSA who are free of overt cardiovascular diseases have early signs of atherosclerosis. All vascular abnormalities correlated significantly with the severity of the OSA, which further supports the hypothesis that OSA plays an independent role in atherosclerosis progression.

Adult↗

PubMed2006

Antioxidant vitamin C improves endothelial function in obstructive sleep apnea.

RATIONALE: Obstructive sleep apnea (OSA) is associated with oxidative stress, endothelial dysfunction, and increased cardiovascular morbidity and mortality. OBJECTIVE: We tested the hypothesis that endothelial dysfunction in patients with OSA is linked to oxidative stress. METHODS: In the present study, we measured flow-mediated dilation (FMD) of the brachial artery by ultrasound in 10 otherwise healthy, untreated patients with OSA and 10 age-and sex-matched control subjects without sleep-disordered breathing before and after intravenous injection of the antioxidant vitamin C. The investigator performing the FMD measurements was blinded to the status of the patients. RESULTS: When compared with control subjects, baseline FMD was significantly reduced in the patients with OSA. After intravenous injection of 0.5 g vitamin C, vasoreactivity remained unchanged in the control subjects. In the patients with OSA, ascorbate led to an increase in FMD to a level comparable to that observed in the control group. CONCLUSION: The reduced endothelial-dependent vasodilation in untreated patients with OSA acutely improves by the free radical scavenger vitamin C. These results are in favor of oxidative stress being responsible for the endothelial dysfunction in OSA. Antioxidant strategies should be explored for the treatment of OSA-related cardiovascular disease.

Administration, Sublingual↗

PubMed2007

Familial premature coronary artery disease mortality and obstructive sleep apnea.

BACKGROUND: Obstructive sleep apnea (OSA) is linked to both coronary artery disease (CAD) and sudden death, but any causal role remains unclear. A family history of premature CAD and related mortality is an independent risk factor for the development of CAD. We hypothesized that OSA is associated with a family history of premature mortality from ischemic heart disease. METHODS: We prospectively studied 588 subjects who underwent polysomnography from May 2000 to June 2004. Demographics, comorbidities, family history of cardiovascular disease, and the ages and causes of death for 10 strata of family members were recorded for all subjects. We excluded those subjects with known causes of premature cardiac death, such as hypertrophic cardiomyopathy and long-QT syndrome. OSA was defined by American Academy of Sleep Medicine criteria (ie, apnea-hypopnea index >or= 5). Premature CAD mortality was defined as death due to ischemic heart disease or sudden cardiac death before 55 years of age (men) or 65 years of age (women). RESULTS: Polysomnography confirmed OSA in 316 subjects and excluded it in 202 subjects. The unadjusted odds ratio (OR) for OSA and a family history of premature CAD mortality was 2.11 (95% confidence interval [CI], 1.10 to 4.31; p = 0.031). After adjusting for each subject's sex, body mass index, and history of CAD, there was a significant and independent association between OSA and family history of premature CAD mortality (OR, 2.13; 95% CI, 1.04 to 4.66; p = 0.046). CONCLUSIONS: Regardless of their own CAD status, people with OSA are more likely than those without OSA to have a family history of premature CAD mortality.

Cause of Death↗

PubMed2006

Serum cardiovascular risk factors in obstructive sleep apnea.

BACKGROUND: Obstructive sleep apnea (OSA) patients have increased cardiovascular morbidity and mortality. The cardiovascular markers associated with OSA are currently not defined. OBJECTIVES: The aims of this study were to determine whether OSA is associated with serum cardiac risk markers and to investigate the relationship between them. METHODS: Sixty-two male patients were classified into two groups with respect to apnea-hypopnea index (AHI): group 1, sleep apnea (n = 30), with AHI > 5; and group 2 (n = 32), with AHI < 5. We compared cardiovascular risk factors in both groups with control subjects (n = 30) without OSA (AHI < 1). Serum cholesterol, triglyceride, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), apolipoprotein A-I, apolipoprotein B, lipoprotein (a), C-reactive protein (CRP), and homocysteine were measured. Statistical significance was assessed with analysis of variance at p < 0.05. In correlation analysis, Pearson correlation was used. RESULTS: There was no significant difference between group 1 and group 2 in total cholesterol, LDL-C, HDL-C, triglyceride, apolipoprotein A-I, apolipoprotein B, and lipoprotein (a). All of the M-mode echocardiographic parameters were in the normal reference range. Serum homocysteine and CRP levels were significantly increased in group 1 compared to group 2 (p < 0.05). Serum CRP values were increased in both group 1 and group 2 when compared with control subjects (p < 0.05). Serum homocysteine values were higher in group 1 than in control subjects (p < 0.05). CONCLUSIONS: Our results show that OSA syndrome is associated not only with slight hyperhomocysteinemia but also with increased CRP concentrations. Increased plasma concentrations of homocysteine and CRP can be useful in clinical practice to be predictor of long-term prognosis for cardiovascular disease and the treatment of OSA.

Adult↗

PubMed2005

Elevated C-reactive protein levels and increased cardiovascular risk in patients with obstructive sleep apnea syndrome.

Obstructive sleep apnea syndrome (OSAS) is associated with cardiovascular morbidity and mortality. Inflammatory processes associated with OSAS may contribute to cardiovascular morbidity in these patients. C-reactive protein (CRP) is an important serum marker of inflammation. We tested the hypothesis that patients with OSAS have increased plasma CRP. After 173 male subjects underwent polysomnography, 94 were considered to have OSAS (apnea-hypopnea index (AHI) > 5), 38 cardiovascular disease (CVD), and 56 without CVD. Seventy-nine subjects were considered not to have OSAS (AHI < 5) and from among these 57 patients without CVD were enrolled as control subjects. Serum CRP levels were significantly elevated in the OSAS + CVD group compared to the two other groups (P < 0.05). When we evaluated the association between the serum CRP level and severity of OSAS, CRP levels were positively correlated with AHI in OSAS patients (r = 0.61, P < 0.001) OSAS, as a marker of inflammation and cardiovascular risk, is associated with elevated levels of CRP. According to these results, the link between cardiovascular morbidity and OSAS may be explained by the coexistence of other cardiovascular risk factors such as circulating CRP levels.

Adult↗

PubMed2001

[Imaging in obstructive sleep apnea syndrome].

Obstructive sleep apneas result from pharyngeal collapse during sleep. Upper airways may be investigated using either static or dynamic techniques during wakefulness or sleep. In OSAS patients, imaging has different goals: to describe the anatomy of the pharynx and the sequence of the pharyngeal collapse, to try to select patients that will benefit from surgery, and to analyze the results of different treatments.

Airway Resistance↗

PubMed2004

[Mandibular advancement devices in the treatment of obstructive sleep apnea].

UNLABELLED: Obstructive sleep apnea (OSA) affects approximately 450,000 people in Poland. Use of nasal continuous positive airway pressure (nCPAP) devices and laryngeal surgery are widely accepted OSA treatment methods. In 1995 ASDA approved oral devices for treatment of OSA patients. The aim of the study was to determine efficiency of mandibular advancement devices (MAD) in OSA therapy. MATERIAL AND METHODS: The study group included 20 patients with OSA, all of whom did not tolerate nCPAP and did not have indications or did not agree for surgical treatment. RESULTS: Control polysomnography was carried out in 11 patients using MAD. In 64% of patients AHI was lower then 10. No correlation between MAD use and AHI values was found. 45% of patients declared improvement of sleep quality and life comfort. CONCLUSIONS: Use of mandibular advancement devices is an important alternative therapy of OSA.

Adult↗

PubMed2006

Histological analysis of palatopharyngeal muscle from children with snoring and obstructive sleep apnea syndrome.

Obstructive sleep apnea syndrome (OSAS) is an upper airway obstruction that occurs during the sleep. One of the suggested mechanisms involved in this process is a neuromuscular abnormality of the palatal muscles. Whether children with OSAS develop into OSAS adults, or children and adult OSAS are two distinct disorders occurring at different ages are questions to be answered. Here, we made the histological analysis of palatophryngeal muscle in 34 oral-breathing children of both genders, aged 5-12 years old, with hypertrophic tonsils and adenoids. According to the polysomnographic study the participants were divided into children without sleeping disorders (group I) and children with primary snoring (group II) or apnea (group III). The main histological findings were fiber size variability in 70% cases from groups II and III and in 71% from group I; perimysial connective tissue infiltration in 48% children from groups II and III and in 71% from group I; intracytoplasmatic mitochondrial proliferation in 63% cases from groups II and III and in 57% cases from group I. Muscle necrosis was only observed in one case, in association with subglandular inflammation. Others findings observed in all groups included fibers with internal architecture alteration, such as moth-eaten and lobulated fibers, type 2 fiber predominance, and small areas of fiber type grouping. The presence of similar histological findings in the palatopharyngeal muscle in children with primary snoring or apnea but also in children without sleeping disorders indicate that such changes could be a normal histological feature of this muscle rather than a neurogenic or myopathic pathology.

Biopsy↗

PubMed2006

Recurrent obstructive apneas trigger early systemic inflammation in a rat model of sleep apnea.

Obstructive sleep apnea (OSA) is associated with vascular disorders possibly due to systemic inflammation. To determine whether repeated episodes of OSA in a rat model lead to endothelial cell activation and systemic leukocyte recruitment in the microcirculation. Three experimental groups (apnea, sham and naive) were studied. The apnea group was instrumented and subjected to repeated obstruction for 3h (rate 60/h, length 5s) using a special device. The sham group was only instrumented and the naive group was used as a control. Leukocyte-endothelial cell interactions (intravital microscopy) and expression of P-selectin (immunohistochemistry) were determined in colonic venules. The apnea group induced a significant increase in the flux of leukocytes rolling, number of rolling leukocytes and number of adherent leukocytes when compared with the sham or naive groups. P-selectin was up-regulated only in the apnea group. This experimental model of recurrent obstruction demonstrates rapid endothelial cell activation, suggesting the onset of an inflammatory response.

Airway Obstruction↗

PubMed2001

Hypercoagulability in patients with obstructive sleep apnea.

BACKGROUND: Obstructive sleep apnea (OSA) has been linked to cardiovascular complications such as stroke and myocardial infarction. Previous studies demonstrate that OSA patients show elevated fibrinogen levels and increased platelet aggregation that are reversed with 1 night of nasal continuous positive airway pressure treatment (NCPAP). Questioning overall coagulability in OSA, we examined whole blood coagulability in 11 chronically NCPAP treated OSA subjects, 22 previously untreated OSA subjects, and in 16 of these after 1 night of NCPAP treatment. PATIENTS AND METHODS: During full polysomnography, subjects from each group had blood drawn prior to bedtime (21:00 h) and upon waking in the morning (07:00 h). RESULTS: Untreated OSA patients had faster P.M. clotting times than chronically treated OSA patients (3.33+/-0.31 versus 6.12+/- 0.66 min, P<0.05 by ANOVA). A.M. values showed similar results (4.31+/- 0.34 min versus 7.08+/-0.52 min, P<0.05 by ANOVA) for the respective groups. One overnight treatment with nasal CPAP did not produce a significant change in A.M. whole blood coagulability (4.35 +/-0.43 to 5.31+/-0.53 min; n=16; P=0.1) in 16 treated subjects. CONCLUSIONS: These data indicate a relationship between obstructive sleep apnea and blood hypercoagulability status that appears to be reversed by chronic NCPAP treatment. These data suggest that NCPAP might protect against the development of cardiovascular complications in OSA patients.

Journal Article↗

PubMed2001

Allergic rhinitis does not constitute a risk factor for obstructive sleep apnea syndrome.

Obstructive sleep apnea syndrome (OSAS) is a condition characterized by recurrent episodes of obstruction of the upper airway. The aim of this study was to evaluate whether nasal obstruction due to allergic rhinitis constitutes a risk factor for OSAS. Patients (n = 119) presenting typical symptoms of sleep apnea were tested for OSAS using polysomnography. Additionally all patients were tested in vivo and in vitro (including nasal eosinophilic cationic protein) for allergic rhinitis. Examination for allergic rhinitis revealed that 88.3% of all patients had no allergic rhinitis, whereas only 11.7% were diagnosed as allergic. No significant differences in sleeping parameters were observed between allergic and non-allergic patients. Comparison of parameters indicative of relevant OSAS (apnea-hypopnea index [AHI] > 10) revealed that 60% of non-allergic patients had relevant OSAS, compared to only 50% of allergic patients. Investigation of allergic subgroups revealed similar results: no significant differences in sleeping parameters or elevated rates of relevant OSAS parameters were observed, especially in perennial allergic rhinitis due to house dust mites. No elevated rates of allergic rhinitis were observed in the studied cohort of patients suffering from sleep apnea or OSAS. Furthermore, no significant differences in sleeping behavior or polysomnography parameters were found on comparing allergic and non-allergic patients. In summary, our data rule out allergic rhinitis as a major risk factor for OSAS.

Electroencephalography↗

PubMed2004

[The sleep obstructive apnea and hypopnea syndromes].

Since two decades, sleep breathing disorders are more wisely recognized by the Belgian medical community. Among these, the Obstructive Sleep Apnea Syndrome (OSA) is the best known but its frontiers with others syndromes such as the Upper Airway Resistance Syndrome (UARS), the Central Sleep Apnea Syndrome (CSAS) or the Overlap Syndrome are still matter of discussion. Its causes are plurifactorial, and many recent publications draw the attention to its long term effects in the cardiovascular and neuropsychiatric fields. This article summarizes the present definitions and features associated with OSA, from clinical and neurophysiological perspectives, and the different consequences to which untreated or underdiagnosed patients are exposed.

Cardiovascular Diseases↗

PubMed1989

[Dentofacial morphology of obstructive sleep apnea syndrome patients].

Sleep apnea syndrome is a condition characterized by recurrent interruption of breathing during sleep. Triad of symptoms for the disease are insomnia, daytime sleepiness and snoring. Recently, the patients complained of these symptoms have progressively increased. And so serious attention has been given to investigate the entity of this new clinical syndrome in medical and dental aspects. Three types of sleep apnea are classified; central, obstructive and mixed type. Most of patients identified this syndrome include obstructive or mixed types of sleep apnea. Obstructive sleep apnea has been presumed to have close relationships with obesity, micrognathia, retrognathia, tonsillary hypertrophy, tongue hypertrophy and so on. This study was designed to evaluate the characteristics of the dentofacial morphology in the obstructive, included mixed, sleep apnea syndrome (OSA) patients. The samples consisted of 25 adult male patients (average age of 48 years 2 months) with OSA as diagnosed by the division of respiratory disease, department of internal medicine, Kanazawa Medical University Hospital. One lateral radiographic cephalogram with the teeth in occlusion and the recording of somatic measurements, body weight and height, were obtained for each patient at visiting our orthodontic clinic. On the lateral cephalograms of whole samples, 10 angular and 6 linear measurements were carried out. Simultaneously, the body mass index (BMI) was assessed for each patient. Based on the cephalometric and somatometric measurements, the pathogenesis of obstructive sleep apnea was discussed in association with the obesity and dentofacial morphology. Results were summarized as follows: 1. The body mass index (kg/m2) ranged between 21.0 to 45.7, with a mean value of 31.0 for OSA patients. Of whom, 3 patients were mildly obese (25 or more of BMI) and 12 patients severely obese (exceeding 30 of BMI). 2. Compared with normal control samples, the means of cephalometric variables of whole samples showed the tendency of micrognathia, large gonial angle, protruded maxilla and large cranial base. 3. By principal component analysis, it was revealed that the components for the shape and position of the mandible were of more importance in OSA patients than controls. 4. Discriminatory analysis clarified significant differences in dentofacial morphology between 12 obese and 13 non-obese patients. 5. The dentofacial morphology in non-obese patients were characterized by retrognathia, micrognathia, large gonial angle and small maxilla. In accordance with previous reports, the patients with OSA were presented the tendency of obesity and micrognathia. Furthermore it was revealed that particularly in non-obese OSA patients the morphological abnormalities might be the major contributor to the pathogenesis of sleep apnea.

Adult↗

PubMed1986

Nasal CPAP therapy, upper airway muscle activation, and obstructive sleep apnea.

In treating obstructive sleep apnea, positive pressure applied through the nose (CPAP) might cause a reflex increase in upper airway muscle activity or might enlarge the airway passively. We studied the effect of CPAP applied by a nasal mask on the electromyographic (EMG) activation of the alae nasi and genioglossal muscles in 8 patients with obstructive apneas during sleep, and correlated EMG activity with concentrations of oxygenation by ear oximeter, and with the end-expiratory position of the rib cage and abdomen by DC-coupled inductance plethysmography. One to 3 cm H2O of CPAP did not eliminate the cyclic occurrence of obstructive apneas. The greatest tonic and phasic EMG activity occurred at apnea termination; the least occurred at apnea onset. With 13 to 15 cm H2O CPAP, apneas were eliminated; mean oxygen saturation rose from 84 +/- 6% (mean +/- SD) to 92 +/- 2%, and EMG activity was reduced or eliminated. With abrupt lowering of CPAP, end-expiratory positions fell, and an obstructive apnea ensued; however, EMG activity did not immediately return. We conclude that the elimination of apneas with CPAP is not attributed to increased EMG activity in the upper airway. The reduction in EMG activity observed with nasal CPAP was closely related to the improvement in hemoglobin oxygen saturation. Therefore, CPAP may act as a pneumatic splint and passively open the upper airway to prevent obstructive apnea.

Electromyography↗

PubMed2007

[Practicability of a surgical multilevel therapy in patients with obstructive sleep apnea].

BACKGROUND: Obstructive sleep apnea syndrome is a "systemic disease" of the upper airways and the upper digestive tract. The concept of multilevel surgery takes account of the fact that the location of the obstruction frequently cannot be identified precisely. PATIENTS AND METHODS: In this retrospective study over 4 years, data on 25 patients (median age 49.9 years) with moderate to severe OSAS treated with a surgical multilevel therapy were statistically evaluated. The treatment carried out consisted in reduction of the inferior turbinate, if necessary combined with septum plasty, and conventional uvulopalatopharyngoplasty (UPPP), combined with tonsillectomy and radiofrequency therapy of the base of the tongue if appropriate. Pre- and postoperative clinical and polysomnographical checks were performed. RESULTS: The mean apnea-hypopnea index (AHI) was 39.2+/-19.7/h before surgery. Postoperatively a highly significant reduction of AHI to 16.5+/-9.9/h (p<0.0001) was seen. In 13 out of 25 patients (52%) the disease was cured (AHI<20 and 50% reduction). In 23 patients the AHI improved. In 15 patients AHI was reduced by more than 50%. CONCLUSION: Multilevel surgery should be considered as an alternative for patients suffering from OSAS, especially in view of the poor long-term results in patients who receive CPAP therapy or are intolerant to CPAP.

Adult↗

PubMedDate not supplied

What are the nonsurgical treatment options for obstructive sleep apnea syndrome?

Obstructive sleep apnea (OSA) syndrome is now recognized as a relatively common cause of excessive daytime sleepiness, with resultant psychosocial impairment and motor vehicle accidents, and it likely contributes to premature cardiovascular disease. Treatment is naturally directed at the upper airway; however, it is also important to identify and correct significant risk factors, such as obesity and hypothyroidism, whenever possible. Oral appliances or nasal continuous positive airway pressure may immediately reverse symptoms caused by OSA and can be used either indefinitely or as a bridge to potentially definitive surgery.

Humans↗

PubMed2004

Does cognitive dysfunction conform to a distinctive pattern in obstructive sleep apnea syndrome?

Obstructive sleep apnea (OSA) is a recognized cause of cognitive dysfunction. By using a cross-sectional comparative study, we aimed to verify whether neuropsychological performance of untreated OSA patients conforms to a distinctive pattern. Forty-nine newly diagnosed, untreated OSA patients, 27 with multi-infarctual dementia (MID), 31 with mild to moderate dementia of Alzheimer type (DAT) and 63 with severe chronic obstructive pulmonary disease (COPD), all free from major comorbid dementing conditions were chosen for the study. The groups were matched for age and education. We found a bimodal distribution of cognitive performance in OSA group, which was therefore divided into two clusters having better (OSAb, n = 35) and worse (OSAw, n = 14) performance on a battery of 10 cognitive indexes. Cognitive performances of OSAb, OSAw, MID, DAT and COPD were compared by discriminant analysis. OSAb performed better than OSAw in all but one test. Deductive thinking and verbal attainment were more severely impaired in OSAw than in COPD patients. Constructive ability, deductive thinking and both verbal attainment and immediate memory were comparably impaired in OSAw and DAT. The mean neuropsychological scores of OSAw and MID were comparable, but 71% of OSAw patients had a distinctive cognitive profile, i.e. a group specific pattern of cognitive dysfunction, according to discriminant analysis. One of four newly diagnosed OSA patients had a severe and distinctive neuropsychological dysfunction mainly involving inductive and deductive thinking, and constructive ability. Some analogy with cognitive pattern of MID suggests that a mainly subcortical damage underlies this dysfunction.

Adult↗

PubMed2001

Non-linear dynamics of cardiovascular system in humans exposed to repetitive apneas modeling obstructive sleep apnea: aggregated time series data analysis.

OBJECTIVE: Testing the hypothesis that alterations in non-linear dynamics of the cardiovascular variability appear in healthy, awake subjects during voluntary apnea. SUBJECTS AND METHODS: Ten young subjects performed 20 apneas 60 s each separated by 1 min free breathing. Inter-beat interval (IBI) measured as RR-interval in ECG, systolic (SYS) and diastolic (DIAS) arterial blood pressure. stroke volume (SV), cardiac output (CO) and total peripheral resistance (TPR) were non-invasively recorded and computed by Portapress 2 system. Correlation dimension according to Grassberger-Proccacia algorithm (CD) and ratio of % determinism versus % recurrence (RDR) computed from recurrence plot according to Webber and Zbiluth [J. Appl. Physiol. 76 (1994) 965] were used as the indices of chaos and complexity. Sequential time series of cardiovascular variables in consecutive 60-s apneas and inter-apnea free breathings were separately windowed and aggregated. CD and RDR of aggregated apneic time series were compared with CD and RDR values of aggregated time series of inter-apnea free breathing, 10 min at rest and 10 min recovery. Reliability of the aggregation method of sequential time series was tested on transformed simulated data generated by Lorenz model. Error in CD and RDR estimation did not exceed 5% and 1%. respectively. RESULTS: CD of cardiovascular variables computed from aggregated apneas was significantly reduced and RDR augmented versus control and recovery periods. CD and RDR values of inter-apnea phases were in between those in control and during apneas. Time domain linear variance (SD) was increased during aggregated apneas. CONCLUSIONS: Signal dynamics dependent windowing and data aggregation could be a useful tool for non-linear analysis of short repeatable sequential time series; time domain linear variability of the cardiovascular dynamics is augmented while complexity reduced during apneic chemoreceptor stimulation; alterations in non-linear dynamics of cardiovascular variables during apneas in healthy normotensive subjects may suggest an early sign of a mechanism implicated in arterial hypertension in OSAS.

Adult↗