RATIONALE:Obstructive sleep apnea (OSA) and hypertension are common comorbidities and are associated with poor prognosis. Blood pressure (BP) trajectories using home BP monitoring after initiation of continuous positive airway pressure (CPAP) therapy for OSA are poorly documented. OBJECTIVES:To describe BP trajectories in the first 6 months after CPAP therapy initiation based on repeated longitudinal measurements of home BP, to evaluate the impact of CPAP on morning and evening home BP, and to identify predictors of home BP evolution during CPAP. METHODS:This prospective cohort study enrolled patients with OSA. Home BP monitoring was used to assess morning and evening home BP values over a 7-day period at baseline and over the first 6 months after starting CPAP therapy. RESULTS:A total of 98 patients were enrolled, and 36,600 home BP measurements were available for analysis. Morning and evening systolic/diastolic home BP decreased significantly during the first 6 months of CPAP therapy (P < 0.05 vs. baseline). Morning home BP was significantly higher than evening home BP throughout the study (P < 0.01). After adjustment for OSA severity at baseline and CPAP adherence, factors associated with limited home BP response to CPAP were older age, weight gain during CPAP therapy, current smoking, and previous hypertension. CONCLUSIONS:CPAP improved home BP trajectories during the first 6 months, but the response was heterogeneous and less marked for morning BP values. Based on the predictors of BP response during CPAP therapy, weight control appears key to the effective management of patients with OSA and hypertension.Clinical trial registered with www. CLINICALTRIALS:gov (NCT04963192 and NCT04054180).

Purpose:A high number of people affected by eating disorders also show severe sleep disturbances, as well as circadian rhythm disruptions. However, research is relatively limited, often yielding conflicting results, especially when comparing clinical populations to healthy controls. Few interventions currently integrate sleep and circadian considerations into ED treatment. This review aims to synthesize recent evidence on sleep and circadian alterations in EDs and to identify research and clinical priorities. Methods:A systematic research through four academic databases was conducted during September 2025, seeking studies on the theme published between 2020-2025. Eligible articles were narratively synthesized to provide a comprehensive and recent overview of the state of the art. Quality appraisal tools were used according to the studies' design. Results:Eleven studies met inclusion criteria. Sleep disturbances were most consistently reported in individuals with anorexia nervosa, including poor sleep quality. Evidence for bulimia nervosa and binge-eating disorder was limited and inconclusive, since only a study was included. Five case-control studies compared clinical populations to healthy controls and three studies assessed the effects of ED-focused treatments on sleep. Two studies evaluated a sleep-specific intervention, while one employed bright light therapy. Objective sleep measures were rarely employed. Conclusion:Sleep and circadian disturbances represent an underexplored but clinically relevant dimension of EDs. This review provides a systematically organized synthesis of recent evidence, clarifies diagnosis-specific patterns, and identifies methodological and intervention gaps. Integrating sleep and circadian considerations into assessment and treatment may enhance rehabilitation outcomes and inform the development of more effective, targeted interventions.

Workers native to sea level and employed in Chilean Andes mines (3800–4500 m) experience Chronic Intermittent Hypobaric Hypoxia (CIHH) due to 7-day high-altitude shifts alternating with 7-day sea-level rest. Hypobaric hypoxia can exacerbate Sleep-Disordered Breathing (SDB), raising cardiovascular risk. Evaluating miners before altitude exposure may help identify SDB risk factors. We described nocturnal respiratory alterations during CIHH and the anthropometric and biological characteristics measured at sea level. In this Cross-sectional study, nocturnal oximetry was performed in miners during high-altitude shifts. Blood samples, blood pressure, and anthropometric data were collected at sea level before ascent. Oxygen Desaturation Index (ODI) ≥ 15/h and time spent with SpO2 < 85

Insomnia is the most prevalent sleep disorder, affecting up to one third of the adult population and is increasingly recognised as a potential contributor to cardiovascular disease (CVD), a leading cause of global morbidity and mortality. This narrative review examines the complex relationship between insomnia and CVD, integrating epidemiological, genetic and mechanistic evidence to assess whether insomnia represents a causal cardiovascular risk factor. Large prospective cohort studies and meta-analyses consistently show that insomnia symptoms and clinically diagnosed insomnia are associated with increased risks of hypertension, myocardial infarction, stroke, heart failure and cardiovascular mortality, with stronger associations observed in individuals with short sleep duration or persistent insomnia. Mendelian randomization studies involving millions of participants further support a likely causal link, suggesting that genetic liability to insomnia increases the risk of multiple cardiometabolic outcomes. Biological plausibility is supported by evidence of autonomic imbalance, hypothalamic-pituitary-adrenal axis activation, inflammation and adverse blood pressure profiles in individuals with insomnia. However, insomnia is a heterogeneous condition, frequently coexisting with other sleep disorders and influenced by psychosocial and circadian factors, which complicates causal inference. Importantly, evidence that treatment of insomnia reduces cardiovascular risk remains limited. While cognitive behavioural therapy for insomnia improves sleep outcomes and some cardiometabolic biomarkers, randomised trials have not demonstrated clear benefits on blood pressure or other cardiovascular endpoints and some pharmacological treatments may even be associated with harm. Overall, current evidence suggests that insomnia is a plausible and potentially causal risk factor for CVD, but definitive proof of reversibility through treatment is lacking. Well-powered, rigorously designed trials targeting patients with clinically defined insomnia are needed to determine whether effective insomnia treatment can meaningfully reduce cardiovascular risk and inform future prevention strategies.

Obstructive sleep apnea (OSA) is a common disorder with significant health and economic burdens and the current standard of diagnosis is performed through polysomnography. This study assesed the diagnostic accuracy of SOUNDI, a novel wearable device that uses optical, acoustical, and accelerometer signals for home sleep testing. Fifty patients suspected of having OSA underwent simultaneous monitoring with standard Type 3 cardiorespiratory monitoring (PG) and SOUNDI system. The apnea‒hypopnea index (AHI), oxygen desaturation index and oxygen saturation parameters derived from SOUNDI were highly correlated (r = 0.87-0.99, p < 0.0001) and were in good agreement with the PG. SOUNDI study was shown to have excellent specificity and positive predictive value (PPV) at various AHI values ( AHI ≥ 5/h: specificity = 0.769, PPV = 0.919; AHI ≥ 15/h: specificity = 0.852, PPV = 0.833; AHI ≥ 30/h: specificity = 0.833, PPV = 0.100). Patient feedback highlighted significant satisfaction with the wearingability and ease of use of the SOUNDI, indicating a preference for multi-night monitoring. The findings suggest that the SOUNDI offers a patient-centric and potentially cost-effective alternative to PG for OSA diagnosis in the home setting.

Introduction Chronic insomnia disorder significantly affects cognitive, emotional, and physical health. Recently, the dual orexin receptor antagonist (DORA) daridorexant was approved for treating chronic insomnia in several countries. Given the limited evidence available, expert consensus was sought to clarify key clinical issues, inform practice, and guide future research. Methods Thirteen Italian sleep experts employed the Nominal Group Technique (NGT) to identify and rank important clinical questions. The process involved independent thought generation, group discussion, and online voting using a 5-point Likert scale. Results The NGT process resulted in 55 statements across five key clinical questions, with relevance scores guiding their categorization into three tiers. Key findings highlight daridorexant's mechanism of action, safety profile, efficacy on night and day parameters, and suitability for long-term use. The experts emphasized cross-tapering strategies for switching from other hypnotics, the importance of sleep psychoeducation, and using the Insomnia Severity Index and sleep diaries for treatment evaluation. Discussion Daridorexant may address insomnia without increasing sedation via its dual orexin receptor antagonism. Daridorexant seems to be effective and safe even in special patient populations, such as the elderly and those with comorbid conditions (neurodegenerative disorders and cognitive impairment, comorbid insomnia and sleep apnea, psychiatric conditions and mood disorders, epilepsy, and restless leg syndrome), thus representing a new, promising option for insomnia treatment. Conclusion The expert consensus provides a comprehensive framework for daridorexant clinical application, advocating for further research to expand the evidence base and refine best practices, as well as underscoring the importance of a multidisciplinary approach that combines both pharmacological and psychosocial interventions to optimize outcomes.

Background Tools like Life’s Simple 7 (LS7) can help estimate the risk of cardiovascular events in healthy subjects. Recently, the Life’s Essential 8 (LE8) was developed, including sleep as an additional variable for a more precise cardiovascular risk estimation. However, it is unclear whether such an increase in complexity is associated with an improvement in the score’s performance. We aimed to test the LS7 and LE8 in a European cohort in order to understand whether adding subjective sleep information could allow a better cardiovascular risk stratification. Methods UK Biobank data were used for computing the cardiovascular scores. Sleep duration was evaluated through questionnaires. The cardiovascular outcomes were fatal and non-fatal CVD events. Multivariable-adjusted logistic and Cox proportional hazards models were used to evaluate associations of the different metrics with CVD prevalence and incidence. The c-statistic was used to quantify differences in incident CVD discrimination. Results A cohort of 106,724 participants (mean age: 55.9 years, 55% males) included 6,130 prevalent and 11,575 incident CVD events (mean follow-up: 12.9 ± 2.7 years). CVH metrics were categorised into tertiles. LS7- and LE8-based metrics effectively characterised prevalent and incident CVD events. LS7 models had similar C-statistics with (0.705, 95% CI: 0.701–0.709) and without (0.706, 95% CI: 0.702–0.710) sleep data. LE8 without sleep (0.708, 95% CI: 0.704–0.712) outperformed LS7 without sleep by 0.002 (95% CI: 0.001–0.003, p < 0.05). However, standard LE8 with sleep (0.706, 95% CI: 0.702–0.710) showed no significant difference from LS7. Conclusions In a European cohort, LS7 and LE8 are useful tools for risk stratification. However, despite the LE8 offering marginally better risk stratification than LS7, the inclusion of subjective sleep did not provide a tangible advantage.

A European Respiratory Society research seminar entitled "Sleep Apnoea and Its Consequences: From Animal Models to Precision Medicine" was held in January 2024 in Lisbon, Portugal. It provided an in-depth analysis of the current landscape and future directions in OSA research, integrating recent findings from metabolomics, animal models, clinical predictors of cardiometabolic consequences of OSA, artificial intelligence (AI), and advances in diagnostic algorithms. This article presents a narrative review of the seminar’s key discussions and conclusions.The limitations of current randomized controlled trials (RCTs) in assessing OSA treatment, such as low adherence and patient selection bias (e.g., absence of sleepiness or severe hypoxemia), were critically discussed. The expert panel recommended the use of real-world data, including patients commonly seen in clinical practice, and the use of digital tools for real-time monitoring of adherence and side effects. The concept of platform "disease-focused" trials was discussed as a more efficient and adaptable research design that could allow clinical trials to be more representative of the general OSA population and to compare CPAP with emerging treatments such as new drugs, devices and lifestyle interventions to gain a broader understanding of effective management strategies.The seminar concluded that a multifaceted approach to OSA research that leverages the strengths of animal models, advanced AI, metabolomics, and improved diagnostic algorithms is needed to gain deeper insights into the mechanisms of OSA and its treatment response. This new approach, coupled with new "platform" clinical trial designs, could contribute to improved outcomes in patients with OSA.

BACKGROUND:Using the apnoea-hypopnoea index (AHI) as the sole determinant for treating obstructive sleep apnoea (OSA) is being critically discussed. The modified Baveno classification is a multicomponent grading tool combining respiratory disturbance, symptoms and cardiovascular disease (CVD) risk assessment to guide treatment of OSA. Retrospective analyses of an existing database showed that treatment according to this classification resulted in significantly improved symptoms and cardiovascular parameters. We report the design of the first prospective study to evaluate the modified Baveno classification. METHODS:Patients with OSA (≥40 years) recruited in this multicentre, prospective, observational long-term follow-up study will be treated with OSA-specific therapy according to the modified Baveno classification. Patients with AHI≥30/h or with established CVD, severe renal disease, diabetes with end-organ damage, difficult-to-treat hypertension or chronic/recurrent atrial fibrillation are associated with strong treatment indication. For the remaining patients, SCORE2/SCORE2-OP/SCORE2-diabetes risk assessment of CVD together with symptom scores, determines the strength of treatment indication. The first hierarchical primary outcome is change in office systolic blood pressure (SBP), followed by Epworth Sleepiness Scale. Follow-up will occur at 6-,12-, 24- and 36-months from baseline. Retrospective data analysis revealed a mean change in SBP of -5±14 mmHg in 393/1081 patients. A power of 99.9 % with a two-sided alpha of 0.001 results in a sample size of 894. The target sample size is 1800 patients, assuming a drop-out rate of 50 % at 3 years. DISCUSSION:This study investigates the clinical relevance of the modified Baveno classification for OSA severity assessment and treatment decision making in clinical practice.

BACKGROUND:Glucagon-like peptide-1 receptor agonists (GLP-1RAs) and dual GIP/GLP-1 agonists have demonstrated weight loss benefits and reductions in obstructive sleep apnoea (OSA) severity. Following recent regulatory approval of tirzepatide for OSA with obesity, their integration into sleep medicine is accelerating. However, real-world clinical practice remains undefined. METHODS:The European Sleep Apnoea Database (ESADA) network conducted a multinational online survey across 24 centres in 14 European countries to evaluate current practice patterns regarding GLP-1RA use in patients with obesity and suspected or established OSA. RESULTS:Forty-two percent of centres reported that GLP-1RA therapy could be initiated by sleep physicians within the sleep clinic. Indications were consistent, primarily targeting moderate-to-severe obesity with metabolic comorbidities. Most clinicians continued to recommend diagnostic sleep studies in symptomatic (92%) and asymptomatic (81%) patients recently started on GLP-1RAs. A weight loss threshold > 10% was considered clinically meaningful for OSA reassessment by 61% of centres. Despite anticipated reductions in OSA severity, proactive positive airway pressure (PAP) re-titration or withdrawal was uncommon (14%). Monitoring focused on weight trajectory, symptoms, and PAP telemonitoring. Structured interdisciplinary pathways were largely absent. CONCLUSIONS:GLP-1RAs are increasingly incorporated into European sleep practice; however, substantial variability exists in diagnostic timing, PAP management, and follow-up strategies. Harmonised guidance and coordinated multidisciplinary care are urgently needed.

Promising methods for monitoring blood pressure (BP) are based on the pulse arrival time (PAT) from finger photoplethysmography (PPG). This study aims to investigate the impact of PPG fiducial points, wavelengths, and PAT calibration models on short-term BP estimations. A multi wavelength multisensor PPG device was developed to measure PAT beat-by-beat in ten volunteers during an exercise protocol. Four calibration models (two-coefficient inverse, squared inverse, and logarithmic; and three-coefficient inverse), four fiducial points (wave onset, peak, maximum derivative, and tangents' intersection), and three wavelengths (red, infrared (IR), and green) were compared to estimate BP on 5-min segments and single beats. Finger systolic and diastolic BP (DBP) served as reference. Estimation errors were higher for systolic than DBP. Acceptable (<5 mmHg) median absolute errors (MAEs) for 5-min average systolic BP (SBP) were achieved by combining red or IR wavelengths with inverse or squared-inverse calibrations. For single-beat estimates, MAEs were higher but remained <8 mmHg with red or IR wavelengths, maximum derivative or tangents' intersection fiducial points, and two-coefficient calibrations. Short-term BP estimation from finger PAT is feasible by properly combining calibration models, wavelengths, and fiducial points. Identifying the optimal parameters for estimating BP from finger PAT by PPG, this study contributes to the development of noninvasive devices for accurate and continuous BP monitoring both in clinical settings and in the general population.

BACKGROUND:A subgroup of patients with obesity exhibits hypoventilation as a result of, among other mechanisms, a narrow, collapsible upper airway (UA), a reduced ventilatory drive during both wakefulness and sleep, and the loss of pharyngeal muscle tone during sleep. These features characterize obesity-hypoventilation syndrome (OHS). If left untreated, OHS is associated with significant morbidity and mortality. Besides lifestyle modifications, positive airway pressure (PAP) is the only available treatment, and it is often not well tolerated. Drugs designed to activate UA muscles such as atomoxetine and to stimulate breathing such as acetazolamide represent a potential novel strategy for treating OHS. RESEARCH QUESTION:Is 2 weeks of 500 mg acetazolamide plus 100 mg atomoxetine daily effective for OHS severity (reduction in mean nocturnal CO2 as the primary outcome)? STUDY DESIGN AND METHODS:In a randomized, double-masked crossover trial, we compared 2 weeks of acetazolamide plus atomoxetine with placebo in patients with OHS not treated with PAP. Patients with a BMI of ≥ 35 kg/m2 underwent polysomnography with transcutaneous overnight measurement of CO2 (Ptcco2) and morning blood test to evaluate sleep-related and diurnal hypercapnia at baseline and after each treatment sequence. RESULTS:Fifteen patients with a median age of 53 years (interquartile range [IQR], 36-59 years; 8 female patients; median BMI, 44 kg/m2 [IQR, 42-53 kg/m2]; baseline median Ptcco2, 49 mm Hg [IQR, 44-55 mm Hg]; median apnea-hypopnea index (AHI), 64 events/h [IQR, 36-83 events/h], and median nocturnal peripheral capillary oxygen saturation (Spo2), 84% [IQR, 79%-89%]) were randomized. Acetazolamide plus atomoxetine decreased nocturnal Ptcco2 by a mean of -5.8 mm Hg (95% CI, -7.8 to -3.7 mm Hg; P < .001) and diurnal CO2 compared with placebo. Median AHI decreased by -20.9 events/h (95% CI, -26.7 to -15.1 events/h; P < .001) and mean overnight Spo2 increased by 4.3% (95% CI, 2.8%-5.7%; P < .001). No serious adverse events occurred. INTERPRETATION:Our results show that the administration of acetazolamide plus atomoxetine significantly improved sleep-related hypoventilation, oxygen parameters, and AHI in treatment-naive patients with OHS. This proof-of-concept study provides encouraging results for a potential pharmacotherapy for OHS. CLINICAL TRIAL REGISTRATION:ClinicalTrials.gov; No.: NCT05448443; URL: www. CLINICALTRIALS:gov.

INTRODUCTION:Excessive daytime sleepiness (EDS) is a symptom of obstructive sleep apnea (OSA) associated with the risk of accidents at work or while driving. OSA treatment decreases EDS, but some patients remain sleepy despite optimal control of OSA. Patients who do not tolerate or refuse OSA treatment may be symptomatically treated for EDS. Solriamfetol and pitolisant are wake-promoting agents (WPA) recently approved for use in sleepy OSA patients accepting or refusing OSA treatment. AREAS COVERED:This narrative review provides updated information on: how to assess EDS in OSA patients, epidemiology, and management of residual EDS in treated OSA patients and the results of recent studies using new WPAs in patients accepting or refusing CPAP treatment. Literature was accessed from PubMed between 1 December 2024 and 6 January 2025. EXPERT OPINION:The new WPAs are useful drugs with a favorable safety profile to be included as a possible therapeutic option for sleepy OSA patients. However, it is still uncertain which subgroups of patients should be treated for the symptom of EDS while maintaining a low-risk profile in terms of the consequences of OSA on health. Until such data is available, use of WPA in OSA patients should be managed by Sleep Specialists.

Interest in the pathophysiology, measurement, and clinical implications of nocturnal blood pressure (BP) has significantly increased due to its strong association with cardiovascular risk, and its importance was recognized by the 2023 European Society of Hypertension (ESH) guidelines. Nocturnal BP regulation is complex and multifactorial, involving sleep-wake cycle, circadian rhythms, autonomic nervous system, renin-angiotensin-aldosterone system, and renal mechanisms. 24-h ambulatory blood pressure monitoring is currently the reference method for nocturnal BP assessment. Home BP monitoring, with specially designed, validated devices with nocturnal BP measuring function, may also be used, while new cuffless and wearable technologies hold great potential but require further validation. Nocturnal BP phenotypes of clinical interest include nocturnal hypertension, increased nocturnal BP variability and altered day-night BP fluctuations. Among those, isolated nocturnal hypertension may be considered a type of masked hypertension. BP variability has prognostic relevance, as do the day-night BP changes, i.e. the nocturnal BP "dipping". Nocturnal hypertension and nondipping are particularly prevalent in individuals with autonomic neuropathies, sleep disorders (e.g., obstructive sleep apnoea), kidney disease, and metabolic or endocrine disorders, and are linked to hypertension mediated organ damage and cardiovascular risk. Therapeutic strategies targeting nocturnal BP remain debated. Chronotherapy (evening dosing of antihypertensives) has shown inconsistent results in clinical trials. Renal denervation and treatment of sleep-related breathing disorders may lower nocturnal BP and improve sleep quality. More research is needed to further clarify pathophysiology, measurement, therapeutic interventions, and overall management of nocturnal hypertension, issues on which this ESH position paper offers an in-depth review.

Purpose This study assesses the role of personal, family-related, and school-related factors in adolescence in the perception of the presence of difficulties in falling asleep. Methods The study used data from the Italian 2022 Health Behavior in School-Aged Children (HBSC) study, focusing on 3201 participants (99.7% of response) from the Italian HBSC sample in Tuscany. Descriptive and hierarchical multivariable logistic regression models including personal, family- and school-related factors were used to assess perceived difficulties in falling asleep as reported by 11-, 13-, 15-, and 17-year-old adolescents. Results Around 49.7% of the sample was female. Nearly a quarter of the adolescents reported sleep difficulty daily or more than once a week. Females reported significantly higher risk of sleep difficulty (odds ratio (OR) of 1.38, 95% CI 1.1-1.7), as did those with higher levels of perceived school pressure (OR 1.47, 95% CI 1.3-1.6) and lack of student support (OR 1.14, 95% CI 1.0-1.3). Those in the middle level of the Family Affluence and older adolescents reported lower risk of sleep difficulty falling asleep (OR 0.74, 95% CI 0.6-0.9 and 0.46, 95% CI 0.3-0.6, respectively). Conclusion Since concurrent factors in different settings have shown to influence the expression of sleep problems, integrated intervention strategies should be applied to promote healthy sleep habits among adolescents. Therefore, it is necessary for invest in multidimensional intervention approaches, taking into account all the key stakeholders such as the individual, the family and the school into a more integrated perspective design.

Spending a single night at moderate altitude before ascending to high altitude may enhance ventilatory acclimatization but also exacerbate sympathetic activation, a response that should be carefully pondered in persons with coronary artery disease (CAD). Ten males with CAD participated in this randomized placebo-controlled crossover trial in a hypobaric chamber, where they slept either at simulated 1,900 m (intervention) or in control conditions (250 m, placebo) before being decompressed to 3,000 m the following morning. Respiratory polygraphy was performed each night. Peripheral oxygen saturation ([Formula: see text]), end-tidal partial pressure of CO2 ([Formula: see text]), cerebral tissue oxygen saturation index (cTSI), baroreflex sensitivity (BRS), heart rate variability (HRV), and pulmonary artery systolic pressure (PASP) were recorded during wakeful rest each morning, both before the overnight stay (at 250 m) and after the simulated ascent to 3,000 m. The intervention night was associated with a greater number of apneas/hypopneas (33 [9, 51] h-1) than placebo (6 [3, 13] h-1, P = 0.02). At 3,000 m, [Formula: see text] was higher after intervention (88 ± 2%) than placebo (87 ± 2%, P = 0.03), [Formula: see text] was lower after intervention (34 ± 3 mmHg) than placebo (36 ± 3 mmHg, P = 0.002), cTSI decrease was smaller after intervention (-3.6 ± 2.2%) than placebo (-6.5 ± 3.1%, P = 0.02), and PASP was higher after intervention (30 ± 8 mmHg) than after placebo (28 ± 7 mmHg, P = 0.04), whereas BRS and HRV indices showed no differences. We conclude that a single night at 1,900 m is sufficient to trigger measurable ventilatory acclimatization in persons with CAD without altering BRS and HRV at 3,000 m, but likely enhancing pulmonary hypoxic vasoconstriction.NEW & NOTEWORTHY We found that a single night spent at simulated moderate altitude (1,900 m) prompts measurable ventilatory acclimatization when ascending to simulated high altitude (3,000 m) in males with coronary artery disease. We also found that, although sleeping at 1,900 m increases the occurrence of apneas and/or hypopneas, this did not modify heart rate variability and baroreflex sensitivity responses at 3,000 m.