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Volume 14 No. 09
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Accepted Papers

Scientific Investigations

CPAP Therapy Delays Cardiovagal Reactivation and Decreases Arterial Renin-Angiotensin System Activity in Humans With Obstructive Sleep Apnea

David D.M. Nicholl, MD, MSc1,2; Patrick J. Hanly, MD1,3,4; Ann A. Zalucky, MD, MSc1,2; Michelle C. Mann, PhD1,2; Jennifer M. MacRae, MD, MSc1,2,5; Marc J. Poulin, PhD, DPhil2,4,6,7,8; George B. Handley, RRT9; Darlene Y. Sola, RN, BScN1,2; Sofia B. Ahmed, MD, MMSc1,2,5
1Department of Medicine, University of Calgary, Calgary, Alberta, Canada; 2Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada; 3Sleep Centre, Foothills Medical Centre, Calgary, Alberta, Canada; 4Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada; 5Alberta Kidney Disease Network, Canada; 6Department of Physiology and Pharmacology, University of Calgary, Calgary, Alberta, Canada; 7Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada; 8Faculty of Kinesiology, University of Calgary, Alberta, Canada; 9Healthy Heart Sleep Company, Calgary, Alberta, Canada

Study Objectives:

Obstructive sleep apnea (OSA) is associated with increased cardiovascular risk. The effect of OSA treatment with continuous positive airway pressure (CPAP) on the cardiovascular response to a stressor is unknown. We sought to determine the effect of CPAP therapy on heart rate variability (HRV) and arterial stiffness, at baseline, in response to, and recovery from a physiological stressor, Angiotensin II (AngII), in humans with OSA.


Twenty-five incident healthy subjects (32% female; 49 ± 2 years) with moderate-severe OSA and nocturnal hypoxia were studied in high-salt balance, a state of maximal renin-angiotensin system (RAS) suppression, before CPAP, and after 4 weeks of effective CPAP therapy (usage > 4 h/night) in a second identical study day. HRV was calculated by spectral power and time domain analysis. Aortic augmentation index (AIx) and carotid-femoral pulse-wave velocity (PWVcf) were measured by applanation tonometry. HRV and arterial stiffness were measured at baseline and in response to AngII challenge (3 ng/ kg/min·30 minutes, 6 ng/kg/min·30 minutes, recovery·30 minutes). The primary outcome was the association between CPAP treatment and HRV and arterial stiffness responses to, and recovery from, AngII challenge. In an exploratory analysis subjects were stratified by sex.


CPAP corrected OSA and nocturnal hypoxemia. CPAP treatment was associated with increased sensitivity and delayed recovery from AngII (Δln HF [high frequency; recovery: −0.09 ± 0.19 versus −0.59 ± 0.17 ms2, P = .042; ΔrMSSD [root mean successive differences; recovery: −0.4 ± 2.0 versus −7.2 ± 1.9 ms, P = .001], ΔpNN50 [percentage of normal waves differing ≥ 50 ms compared to the preceding wave; AngII: 1.3 ± 2.3 versus −3.0 ± 2.4%, P = .043; recovery: −0.4 ± 1.4 versus −6.0 ± 1.9%, P = .001], all values pre-CPAP versus post-CPAP treatment). No differences were observed by sex. There was increased AIx sensitivity to AngII after CPAP among men (8.2 ± 1.7 versus 11.9 ± 2.2%, P = .046), but not women (11.4 ± 1.5 versus 11.6 ± 2.1%, P = .4). No change in PWVcf sensitivity was observed in either sex.


CPAP therapy was associated with delayed cardiovagal reactivation after a stressor and down-regulation of the arterial RAS. These findings may have important implications in mitigating cardiovascular risk in both men and women with OSA.


Nicholl DD, Hanly PJ, Zalucky AA, Mann MC, MacRae JM, Poulin MJ, Handley GB, Sola DY, Ahmed SB. CPAP therapy delays cardiovagal reactivation and decreases arterial renin-angiotensin system activity in humans with obstructive sleep apnea. J Clin Sleep Med. 2018;14(9):1509–1520.

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