More Than a Snore

“Sleep apnea… the not-so-silent killer”

Sleep apnea can cause many, many problems:

Stroke

  • Patients with moderate to severe OSA are 3x more likely to have a stroke
  • The risk of stroke rises with the severity of the disease
  • OSA is often found in patients following a stroke

Heart Problems

High Blood Pressure

Congestive Heart Failure

  • Newly diagnosed patients shuldl be screened for OSA

Cardia Arrhythmias

  • 4x as likely to have atrial fibrillation

Sudden Death

  • Patients with OSA have a 30% higher risk of heart attack or premature death

Poor Sleep

  • Many patients may not be aware of their poor sleep quality

Mood Disturbance

  • Depression
  • Anxiety
  • Loss of motivation
  • Shortened attention span
  • Moodiness and bad temper
  • Low testosterone

Daytime Sleepiness

  • 7x more likely to have a car accident
  • Impaired concentration and memory loss
  • Reduced work efficiency
  • Reduced alertness
  • Slower reaction

Loud Snoring

  • Relationship discord
  • Morning headaches

Diabetes Type 2

  • Treatment of sleep apnea may aid in the control of blood sugar levels

Obesity

  • As sleep shortens or diminishes in quality, appetite for high calorie foot increases
  • Approximately 80% of OSA patients are overweight

Gastroesophageal Reflux Disease (GERD)

Possible treatment options are

  • Weight loss
  • Heartburn medications
  • CPAP therapy (continuous positive airway pressure)

Sex Drive

  • Loss of libido
  • Erectile dysfunction

Frequent Night-time Urination

Chronic Pain

  • Up to 80% of patients with fibromyalgia have sleep apnea
  • 75% of patients treated with moderate to high doses of opioid have sleep apnea

Notes

  1. Young, T., et al., NEJM 1993;328:1230-1235
  2. Young T., et al., AJRCCM 2002;165:1217-1239
  3. O’Connor, et al., Sleep 2003;26(1):74-79
  4. Hiestand, D.M., et al., Chest 2006;130:780-786
  5. Mehra, R., et al., AJRCCM 2006;173:910-916
  6. Peppard, P., et al., NEJM 2000;342:1378-1384
  7. Javahari, S., Curr Treat Options in CV Med 2005;7:295-306
  8. Sin, D., et al., AJRCCM 1999;160:1101-1106
  9. Yaggi, H.K., et al., NEJM 2005;353:2034-2041
  10. Arzt, M., et al., AJRCCM 2005;172:1447-1451
  11. Reichmuth, K.J., et al., AJRCCM 2005;172:1590-1595
  12. Chobanian, A.V., et al., JAMA 2003;289:2560-2571
  13. Hunt, S.A., et al., Circulation 2005;112:1825-1852
  14. Gami, A.S., et al., Circulation 2004;110:364-367
  15. Marin, J.M., et al., Lancet 2005;365:1046-1053
  16. Doherty, L.S., et al., Chest 2005;127:2076-2084
  17. Hla, K.M., et al., Chest 2002;122:1125-1132
  18. Faccenda, J.F., AJRCCM 2001:163:344-348
  19. Pepperell, J.C., Lancet 2002;359:204-210
  20. Heinrich, F., et al., Circulation 2002;107:68-73
  21. Logan, A.G., et al., Eur Respir J 2003;21:241-247
  22. Akashiba, et al., Sleep 1999;22(7):849-853
  23. Bradley, T.D., et al., NEJM 2003;348:1233-1241
  24. Naughton, M.T., et al., AJRCCM 2004;169:361-366
  25. Kenaglala, R., et al., Circulation 2003;107:2589-2594

Sleep Apnea

There are different types of sleep apnea. 

Obstructive Sleep Apnea (OSA)

OSA is the absence of airflow due to an occlusion in the upper airway that lasts at least 10 seconds in spite of continual effort to breathe. Severity is measured by the Apnea / Hypopnea Index (AHI)—the number of episodes per hour of sleep.

wave illustration 1 — 3 pulses in top line, one in bottom line

Central Apnea and Periodic Breathing

Central apnea is the absence of airflow that lasts at least 10 seconds with in inspiratory effort. Period breathing is defined as alternating periods of hyperventilation with waxing/waning tidal volume and periods of central hypopneas or apneas. There are many forms of periodic breathing, one of which is Cheyne-Stokes Respiration (CSR).

wave illustration 2 — 3 pulses in both top and bottom line

Prevalence of OSA 

How common is sleep apnea?

  • The prevalence of OSA is approximately 24% in men and 9% in women
  • 1 to 5% of children are known to have OSA
  • It is estimated that 85 to 90% of patients have not been identified 1
  • One in four patients is at risk for OSA, 2,4

Comorbidity—Sleep Apnea and Cardiac Disease

OSA has been independently associated with an increased risk of cardiac arrhythmias, hypertension, heart failure, stroke, Type 2 diabetes, and coronary artery disease. A large percentage of patients with OSA remains undiagnosed.

circle illustration

Sleep-disordered breathing (SDB) has been associated with various forms of cardiovascular disease.

  • Individuals with severe SDB are 2 to 4 times more likely to develop complex arrhythmias than those without SDB. 5
  • Individuals with diagnosed OSA are between 2 and 3 times more likely to develop hypertension. 6
  • The prevalence of OSA in patients with heart failure is estimated at 40 to 70 percent. 7,8
  • Individuals with diagnosed OSA are more likely to suffer a stroke than those without OSA. 9,10
  • Type 2 diabetes is more prevalent in patients with SDB independent of the other risk factors. 11

Hypertension

  • Sleep apnea has been associated with the development of hypertension in a dose-response relationship. 6
  • NHI / NHILBI JNC7 recognizes OSA as a identifiable cause of hypertension and recommends screening newly identified hypertension patients or patients who develop refractory hypertension for OSA. 12

Heart Failure

  • American College of Cardiology / American Heart Association Heart Failure Guidelines recognize OSA as a possible cause of heart failure and recommend screening newly identified heart failure patients for OSA. 13

Arrhythmias

  • OSA is associated with a significant risk of atrial fibrillation, even after controlling for known confounding parameters. 14
  • 49 percent of patients with atrial fibrillation have OSA, while 32 percent of the general cardiology practice have OSA. 14

Cardiovascular Outcomes with Treated vs. Untreated OSA

Look at this chart to see the difference between treated and untreated obstructive sleep apnea.

bar graph — add superscript 16

problem—I can’t figure out the bottom axis or why deaths have only two bars, not 4

Results of Effective Treatment of OSA

Cardiovascular outcomes in patients treated for OSA vs. patients with untreated OSA:

  • Patients with untreated OSA were 2.68 times more likely to suffer a non-fatal cardiovascular event compared to those whose OSA was effectively treated with CPAP. 15
  • Patients with untreated OSA were 2.5 times more likely to suffer a fatal cardiovascular event compared to those whose OSA was effectively treated with CPAP. 15

Treatment of OSA can positively impact hypertension.

  • Reduced daytime blood pressure in patients whose OSA is effectively treated 17,18,19,20
  • Effective treatment of OSA resulted in reduced systolic blood pressure in refractory hypertension patients with OSA (avg. systolic BP reduced from 138.3 mm Hg to 126 mm Hg) . 21
  • Normalized nocturnal blood pressure pattern (restored dipper status) in a non-dipper OSA population whose OSA was effectively treated. 22

Treatment of OSA can positively impact heart failure.

  • Effective treatment of OSA resulted in improved Left Ventricular Ejection Fraction percent (from 25% to 34%), Left Ventricular End Systolic Diameter (from 55 mm to 52 mm), and systolic blood pressure (from 126 mmHG to 116 mmHG) in heart failure patients with OSA. 23
  • Significantly improved quality of life for heart failure patients whose OSA was effectively treated. 24

Treatment of OSA can positively impact arrhythmias.

  • Appropriate treatment of OSA was associated with a reduction in atrial fibrillation recurrence after cardioversion. 25
  • Untreated OSA is associated with an increased rate of occurrence of atrial fibrillation and severity of nocturnal oxygen desaturation. 25

photo?

Treatment of OSA with CPAP Therapy

Continuous Positive Airway Pressure (CPAP) treats OSA by providing a pneumatic splint to keep the patient’s airway open during sleep. Treatment of OSA with CPAP therapy improves sleep-related breathing. Adequately treated OSA also has been associated with improved cardiovascular outcomes.