Background: Obstructive sleep apnea (OSA) is a highly prevalent disorder that has been associated with an increased risk for cardiovascular morbidity, even in children. However, not all children with OSA manifest alterations in endothelial postocclusive hyperemia, an endothelial nitric oxide synthase (eNOS)-dependent response. Since expression of the eNOS gene is regulated by epigenetic mechanisms and OSA may cause epigenetic modifi cations such as DNA hypermethylation, we hypothesized that epigenetic modifi cations in the eNOS gene may underlie the differential vascular phenotypes in pediatric OSA. Methods: Age-, sex-, ethnicity-, and BMI-matched prepubertal children with polysomnographically confi rmed OSA and either normal (OSAn) or abnormal (OSAab) postocclusive hyperemic responses, assessed as the time to attain peak reperfusion fl ow (Tmax) by laser Doppler fl owmetry, were recruited. Blood genomic DNA was assessed for epigenetic modifi cations in the eNOS gene using pyrosequencing. Children with no evidence of OSA or endothelial dysfunction served as a control group. Results: The study comprised 36 children with OSA (11 with OSAab and 25 with OSAn) and 35 children in the control group. Overall, the mean age was 7.5 Ϯ 2.4 years, 65% were boys, and 30% were obese; mean apnea-hypopnea index was 18 Ϯ 8.6/h of sleep for the children with OSA. Tmax was 66.7 Ϯ 8.8 s in the OSAab group and 30.1 Ϯ 8.3 s in the OSAn group ( P , .001). Pyrosequencing of the proximal promoter region of the eNOS gene revealed no signifi cant differences in six of the seven CpG sites. However, a CpG site located at position -171 (relative to transcription start site), approximating important transcriptional elements, displayed signifi cantly higher methylation levels in the OSAab group as compared with the OSAn or control groups (81.5% Ϯ 3.5%, 74.8% Ϯ 1.4%, and 74.5% Ϯ 1.7%, respectively; P , .001). eNOS mRNA expression levels were assessed in a separate group of children and were signifi cantly reduced in the OSAab group in comparison with the OSAn group. Conclusions: The presence of abnormal eNOS-dependent vascular responses in children with OSA is associated with epigenetic modifi cations in the eNOS gene.
CHEST 2013; 143(4):971-977Abbreviations: eNOS 5 endothelial nitric oxide synthase; EPC 5 endothelial progenitor cell; NO 5 nitric oxide; OSA 5 obstructive sleep apnea; OSAab 5 obstructive sleep apnea with delays in postocclusive hyperemic response; OSAn 5 obstructive sleep apnea with normal hyperemic response; Tmax 5 the time to attain peak reperfusion fl ow