LUCIANO FERREIRA DRAGER

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Departamento de Clínica Médica, Faculdade de Medicina - Docente
Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina - Médico
LIM/63, Hospital das Clínicas, Faculdade de Medicina - Líder

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  • article 539 Citação(ões) na Scopus
    Obstructive Sleep Apnea A Cardiometabolic Risk in Obesity and the Metabolic Syndrome
    (2013) DRAGER, Luciano F.; TOGEIRO, Sonia M.; POLOTSKY, Vsevolod Y.; LORENZI-FILHO, Geraldo
    Obstructive sleep apnea (OSA) is an underdiagnosed condition characterized by recurrent episodes of obstruction of the upper airway leading to sleep fragmentation and intermittent hypoxia during sleep. Obesity predisposes to OSA, and the prevalence of OSA is increasing worldwide because of the ongoing epidemic of obesity. Recent evidence has shown that surrogate markers of cardiovascular risk, including sympathetic activation, systemic inflammation, and endothelial dysfunction, are significantly increased in obese patients with OSA versus those without OSA, suggesting that OSA is not simply an epiphenomenon of obesity. Moreover, findings from animal models and patients with OSA show that intermittent hypoxia exacerbates the metabolic dysfunction of obesity, augmenting insulin resistance and nonalcoholic fatty liver disease. In patients with the metabolic syndrome, the prevalence of moderate to severe OSA is very high (similar to 60%). In this population, OSA is independently associated with increased glucose and triglyceride levels as well as markers of inflammation, arterial stiffness, and atherosclerosis. A recent randomized, controlled, crossover study showed that effective treatment of OSA with continuous positive airway pressure for 3 months significantly reduced several components of the metabolic syndrome, including blood pressure, triglyceride levels, and visceral fat. Finally, several cohort studies have consistently shown that OSA is associated with increased cardiovascular mortality, independent of obesity. Taken together, these results support the concept that OSA exacerbates the cardiometabolic risk attributed to obesity and the metabolic syndrome. Recognition and treatment of OSA may decrease the cardiovascular risk in obese patients. (C) 2013 by the American College of Cardiology Foundation
  • article 16 Citação(ões) na Scopus
    Screening for Obstructive Sleep Apnea in Patients with Atrial Fibrillation
    (2017) GENTA, Pedro R.; DRAGER, Luciano F.; LORENZI FILHO, Geraldo
  • article 12 Citação(ões) na Scopus
    Impact of CPAP on arterial stiffness in patients with obstructive sleep apnea: a meta-analysis of randomized trials
    (2021) CHALEGRE, Sintya T.; LINS-FILHO, Ozeas L.; LUSTOSA, Thais C.; FRANCA, Marcus V.; COUTO, Tarcya L. G.; DRAGER, Luciano F.; LORENZI-FILHO, Geraldo; BITTENCOURT, Marcio S.; PEDROSA, Rodrigo P.
    Purpose This study aimed to perform a systematic review and meta-analysis of randomized trials investigating the effect of continuous positive airway pressure (CPAP) on non-invasive markers of arterial stiffness in patients with OSA. Methods The purpose of the study was to evaluate the effect of CPAP on markers of arterial stiffness (pulse wave velocity (PWV) and augmentation index (Aix)) in patients with OSA. The study adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We systematically reviewed MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, and LILACS databases for randomized trials (RT) evaluating the changes in markers of arterial stiffness (pulse wave velocity (PWV) and augmentation index (Aix) comparing CPAP vs. controls in patients with OSA. Reviewer Manager version 5.3 (R Foundation for Statistical Computing, Vienna, Austria) was used to perform meta-analysis. Risk of bias analysis was performed using the Cochrane tool. Results Of the 464 studies initially retrieved, 9 relevant studies with 685 participants were included in the analysis. The studies presented moderate risk of bias. CPAP did not significantly reduce Aix (mean difference, - 1.96 (95% confidence interval (CI) - 5.25 to 1.33), p = 0.24), whereas it significantly changed PWV (mean difference, - 0.44 (95% confidence interval (CI) - 0.76 to - 0.12), p = 0.00). Conclusion CPAP treatment was effective in improving arterial stiffness by reducing PWV in patients with OSA. Additional randomized trials, however, should be performed to confirm these findings.
  • article 3 Citação(ões) na Scopus
    Pharmacological treatment for central sleep apnoea in adults
    (2023) ROCHA, Aline; PINTO, Ana Carolina Pereira Nunes; V, Daniela Pachito; DRAGER, Luciano F.; LORENZI-FILHO, Geraldo; ATALLAH, Alvaro N.
    Background The term central sleep apnoea (CSA) encompasses diverse clinical situations where a dysfunctional drive to breathe leads to recurrent respiratory events, namely apnoea (complete absence of ventilation) and hypopnoea sleep (insuOicient ventilation) during sleep. Studies have demonstrated that CSA responds to some extent to pharmacological agents with distinct mechanisms, such as sleep stabilisation and respiratory stimulation. Some therapies for CSA are associated with improved quality of life, although the evidence on this association is uncertain. Moreover, treatment of CSA with non-invasive positive pressure ventilation is not always eOective or safe and may result in a residual apnoea-hypopnoea index. Objectives To evaluate the benefits and harms of pharmacological treatment compared with active or inactive controls for central sleep apnoea in adults. Search methods We used standard, extensive Cochrane search methods. The latest search date was 30 August 2022. Selection criteria We included parallel and cross-over randomised controlled trials (RCTs) that evaluated any type of pharmacological agent compared with active controls (e.g. other medications) or passive controls (e.g. placebo, no treatment or usual care) in adults with CSA as defined by the International Classification of Sleep Disorders 3rd Edition. We did not exclude studies based on the duration of intervention or follow-up. We excluded studies focusing on CSA due to periodic breathing at high altitudes. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were central apnoea-hypopnoea index (cAHI), cardiovascular mortality and serious adverse events. Our secondary outcomes were quality of sleep, quality of life, daytime sleepiness, AHI, all-cause mortality, time to life-saving cardiovascular intervention, and non-serious adverse events. We used GRADE to assess certainty of evidence for each outcome.Main results We included four cross-over RCTs and one parallel RCT, involving a total of 68 participants. Mean age ranged from 66 to 71.3 years and most participants were men. Four trials recruited people with CSA associated with heart failure, and one study included people with primary CSA. Types of pharmacological agents were acetazolamide (carbonic anhydrase inhibitor), buspirone (anxiolytic), theophylline (methylxanthine derivative) and triazolam (hypnotic), which were given for between three days and one week. Only the study on buspirone reported a formal evaluation of adverse events. These events were rare and mild. No studies reported serious adverse events, quality of sleep, quality of life, all-cause mortality, or time to life-saving cardiovascular intervention.
  • article 31 Citação(ões) na Scopus
    Effectiveness of continuous positive airway pressure in lowering blood pressure in patients with obstructive sleep apnea: a critical review of the literature
    (2016) FATURETO-BORGES, Fernanda; LORENZI-FILHO, Geraldo; DRAGER, Luciano F.
    Obstructive sleep apnea (OSA) is an extremely common comorbid condition in patients with hypertension, with a prevalence of similar to 50%. There is growing evidence suggesting that OSA is a secondary cause of hypertension, associated with both poor blood pressure (BP) control and target organ damage in patients with hypertension. The application of continuous positive airway pressure (CPAP) during sleep is the gold standard treatment of moderate-to-severe OSA and very effective in abolishing obstructive respiratory events. However, several meta-analyses showed that the overall impact of CPAP on BP is modest (similar to 2 mmHg). There are several potential reasons for this disappointing finding, including the heterogeneity of patients studied (normotensive patients, controlled, and uncontrolled patients with hypertension), non-ideal CPAP compliance, clinical presentation (there is some evidence that the positive impact of CPAP on lowering BP is more evident in sleepy patients), and the multifactorial nature of hypertension. In this review, we performed a critical analysis of the literature evaluating the impact of CPAP on BP in several subgroups of patients. We finally discussed perspectives in this important research area, including the urgent need to identify predictors of BP response to CPAP and the importance of precision medicine in this scenario.
  • article 16 Citação(ões) na Scopus
    Obstructive sleep apnea and ambulatory blood pressure monitoring: current evidence and research gaps
    (2021) PIO-ABREU, Andrea; MORENO JR., Heitor; DRAGER, Luciano F.
    Obstructive Sleep Apnea (OSA) is a common condition characterized by intermittent collapse of the upper airway during sleep, resulting in partial (hypopnoeas) and total obstructions (apneas). These respiratory events observed in OSA may trigger multiple pathways involved in the blood pressure (BP) instability during the night and potentially influencing daytime BP as well (carry-over effects). This review provides an update about the impact of OSA and its treatments on 24-h BP control. Overall, there is growing evidence suggest that OSA is associated with higher frequency of nondipping BP pattern and nocturnal hypertension in a dose-dependent manner. The presence of nondiping BP (especially the reverse pattern) is independently associated with OSA regardless of sleep-related symptoms suggesting a potential tool for screening OSA in patients with clinical indication for performing ABPM. Beyond dipping BP, preliminary evidence associated OSA with white-coat effect and higher frequency of masked hypertension and BP variability than the control group (no OSA). Unfortunately, most of the evidence on the evidence addressing the impact of OSA treatment on BP was limited to office measurements. In the last years, data from observational and randomized studies pointed that CPAP is able to promote 24-h BP decrease especially in patients with resistant and refractory hypertension. A randomized trial suggests that CPAP is able to decrease the rate of masked hypertension as compared to no treatment in patients with severe OSA. Interestingly, nondipping BP is a good predictor of BP response to CPAP making ABPM an interesting tool for better OSA management.
  • article 1 Citação(ões) na Scopus
    2023 Guidelines on the Diagnosis and Treatment of Insomnia in Adults - Brazilian Sleep Association
    (2023) DRAGER, Luciano Ferreira; ASSIS, Marcia; BACELAR, Andrea Frota Rego; POYARES, Dalva Lucia Rollemberg; CONWAY, Silvia Goncalves; PIRES, Gabriel Natan; AZEVEDO, Alexandre Pinto de; CARISSIMI, Alicia; ECKELI, Allan Luiz; PENTAGNA, Alvaro; ALMEIDA, Carlos Mauricio Oliveira; FRANCO, Clelia Maria Ribeiro; SOBREIRA, Emmanuelle Silva Tavares; STELZER, Fernando Gustavo; MENDES, Giuliana Macedo; MINHOTO, Gisele Richter; LINARES, Ila Marques Porto; SOUSA, Ksdy Maiara Moura; GITAI, Livia Leite Goes; SUKYS-CLAUDINO, Lucia; SOBREIRA-NETO, Manoel Alves; ZANINI, Marcio Andrei; MARGIS, Regina; MARTINEZ, Sandra Cristina Goncalves
    Chronic insomnia disorder (simplified in this document as insomnia) is an increasingly common clinical condition in society and a frequent complaint at the offices of different areas of health practice (particularly Medicine and Psychology). This scenario has been accompanied by a significant evolution in treatment, as well as challenges in approaching patients in an appropriately way. This clinical guideline, coordinated by the Brazilian Sleep Association and the Brazilian Association of Sleep Medicine and counting on the active participation of various specialists in the area, encompasses an update on the diagnosis and treatment of insomnia in adults. To this end, it followed a structured methodology. Topics of interest related to diagnosis were written based on theoretical framework, evidence in the literature, and professional experience. As for the topics related to the treatment of insomnia, a series of questions were developed based on the PICO acronym (P - Patient, problem, or population; I - Intervention; C - Comparison, control, or comparator; O - Outcome). The work groups defined the eligible options within each of these parameters. Regarding pharmacological interventions, only the ones currently available in Brazil or possibly becoming available in the upcoming years were considered eligible. Systematic reviews were conducted to help prepare the texts and define the level of evidence for each intervention. The final result is an objective and practical document providing recommendations with the best scientific support available to professionals involved in the management of insomnia.
  • article 9 Citação(ões) na Scopus
    Economic evaluation of CPAP therapy for obstructive sleep apnea: a scoping review and evidence map
    (2022) PACHITO, Daniela V.; BAGATTINI, Angela M.; DRAGER, Luciano F.; ECKELI, Alan L.; ROCHA, Aline
    Purpose To synthesize findings of economic evaluations investigating cost-effectiveness of continuous positive airway pressure (CPAP) for obstructive sleep apnea (OSA) and of strategies of organization of care related to CPAP therapy. Methods Scoping review with searches conducted in MEDLINE, CRD, LILACS, and Embase in August 2020. Eligible studies were economic evaluations comparing CPAP to other alternative or assessing strategies of care for CPAP therapy. Results were presented narratively, and incremental cost-effectiveness ratios (ICER) were presented in evidence maps. Results Of 34 studies, 3 concluded that CPAP is less costly and more effective when compared to usual care. Most studies indicated that CPAP is associated with better health outcomes, but at higher prices. ICER ranged from USD 316 to 98,793 per quality-adjusted life years (QALY) gained (median 16,499; IQR 8267 to 33,119). One study concluded that CPAP is more costly and less effective, when treatment is applied to all patients, regardless of disease severity. Variability of ICER was mainly due to definition of population and applied time horizons. When CPAP was compared to mandibular advancement device, ICER ranged from USD 21,153 to 361,028 (median 89,671; IQR 26,829 to 295,983), which represents the investment in CPAP therapy required to obtain one extra QALY. Three studies assessed the effects of organizing CPAP therapy in primary care, which was cost-effective or cost-saving. Conclusions Compared to usual care, CPAP is cost-effective after the second year of treatment, when indicated for moderate-to-severe OSA. CPAP therapy may be even more cost-effective by using different strategies of organization of care. These findings may inform decision making related to CPAP reimbursement in health systems.
  • article 11 Citação(ões) na Scopus
    Resistant Hypertension: Time to Consider the Best Fifth Anti-Hypertensive Treatment
    (2018) PIO-ABREU, Andrea; DRAGER, Luciano F.
    Resistant hypertension (RH) is a growing clinical condition worldwide associated with target-organ damage and poor prognosis compared to non-resistant counterparts. The purpose of this review is to perform a critical evaluation of preferable drug choices for managing RH highlighting the evidence that significant proportion of patients remained uncontrolled despite using four anti-hypertensive drugs. Until recently, the fourth drug therapy was main derived from personal opinion or small interventional studies. The recent data derived from two multicentric randomized trials, namely PATHWAY-2 and ReHOT, pointed spironolactone as the preferable fourth drug therapy in patients with confirmed RH as compared to bisoprolol and doxazosin (PATHWAY-2) as well as clonidine (ReHOT). However, significant proportion of patients (especially observed in ReHOT trial that used 24-h ambulatory blood pressure monitoring) did not achieve optimal blood pressure with the fourth drug. This finding underscores the need of new approaches and treatment options in this important research area. The current evidence pointed that significant proportion of RH patients are requiring more than four drugs for controlling BP. This statement is particularly true considering the new criteria proposed by the 2017 Guidelines for diagnosing RH (> 130 x 80 mmHg). New combinations, drugs, or treatments should be tested aiming to reduce the RH burden. Based on the aforementioned multicentric trials, we proposed the first five preferable anti-hypertensive classes in the overall context of RH.
  • article 86 Citação(ões) na Scopus
    Translational approaches to understanding metabolic dysfunction and cardiovascular consequences of obstructive sleep apnea
    (2015) DRAGER, Luciano F.; POLOTSKY, Vsevolod Y.; O'DONNELL, Christopher P.; CRAVO, Sergio L.; LORENZI-FILHO, Geraldo; MACHADO, Benedito H.
    Obstructive sleep apnea (OSA) is known to be independently associated with several cardiovascular diseases including hypertension, myocardial infarction, and stroke. To determine how OSA can increase cardiovascular risk, animal models have been developed to explore the underlying mechanisms and the cellular and end-organ targets of the predominant pathophysiological disturbance in OSA-intermittent hypoxia. Despite several limitations in translating data from animal models to the clinical arena, significant progress has been made in our understanding of how OSA confers increased cardiovascular risk. It is clear now that the hypoxic stress associated with OSA can elicit a broad spectrum of pathological systemic events including sympathetic activation, systemic inflammation, impaired glucose and lipid metabolism, and endothelial dysfunction, among others. This review provides an update of the basic, clinical, and translational advances in our understanding of the metabolic dysfunction and cardiovascular consequences of OSA and highlights the most recent findings and perspectives in the field.