Non-High Frequency Heart Rate Chaos: A Noninvasive Marker of REM Sleep and Obstructive Sleep Apnea Syndrome in Children

Obstructive sleep apnea syndrome (OSAS) is a highly prevalent condition associated with considerable metabolic, cardiovascular, and neurocognitive morbidity. Childhood OSAS is underdiagnosed due to a limited number of sleep laboratories and the lack of a screening test, and the subtlety of daytime symptoms in children compared to adults. A potential marker of OSAS is apnea-induced sympathoexcitation, which is likely to be exacerbated during rapid-eyemovement (REM) sleep. However, traditional methods of assessing sympathetic activity are either too invasive or insensitive/nonspecific for clinical use, particularly as a screening test. Study population comprised pediatric patients with OSAS (16 moderate/severe, 18 mild) and 18 normal non-snoring controls. We show that the chaotic dynamics of heart rate variability (HRV) as assessed by a sensitive noise titration assay is significantly increased during REM compared to non-REM sleep in children, particularly those with OSAS. The increase in heart rate chaos prevails in the face of decreased parasympathetic-mediated high-frequency component of the HRV power spectrum, indicating that the chaos was correlated to sympathetic instead of parasympathetic activity. Receiver operating characteristic analysis shows that such non-high frequency chaos reveals changing sympathetic-parasympathetic activities that are not discernible by conventional HRV metrics such as low- to high-frequency power ratio or sample entropy, with sensitivity and specificity sufficient to detect even mild OSAS in children. Results suggest a possible role for non-high frequency heart rate chaos as a selective noninvasive marker of sympathoexcitation in REM sleep, OSAS and potentially other cardiovascular abnormalities such as congestive heart failure.