Transcript available here - Sleep Apnoea Association of New Zealand

Sleep Apnea in the
Cardiac Patient
Stephen Jennison
What is the impact of Sleep apnea on
cardiovascular disease?
• Which came first: sleep apnea or CV disease?
• More research is needed per AHA and ACC
• Difficult to decide impact due to multiple comorbidities of obesity, diabetes and metabolic
syndrome
SDB Impact on the Cardiovascular
System
• Both OSA & CSA occur commonly in
patients with cardiovascular disease and
HF and may contribute to disease
progression.
Sympathetic
Parasympathetic
Constrict
Dilate
Stop secretion
Secrete saliva
Spinal
cord
Parasympathetic
Sympathetic
ganglion
chain
Constrict bronchioles
Dilate bronchioles
Speed up heartbeat
Secrete adrenaline
Decrease secretion
Slow down heartbeat
Adrenal
gland
Increase secretion
Stomach
Increase motility
Decrease motility
Empty colon
Retain colon contents
Empty bladder
Delay emptying
Parasympathetic
Bladder
Sympathetic
Activation
Increased RR
Increased mental
activity
Wakefulness
Airway Patency
Compensation
Sleep
Arousal &
Hyperventilation
O2 &
Increased BP
HR Increased
Increased release of
glucose
CO2
Decreased
Compensation
Sympathetic Activation
Airway Collapse
O2 &
CO2
OSA Impacts:
Sympathetic Nerve Activity, Blood
Pressure, Oxygenation etc.
Sympathetic
Nerve Activity
RESP
OSA
OSA
OSA
250
BP
125
0
Somers VK et al. J Clin Invest. 1995;96:1897.
Studies Linking OSA and
Cardiovascular Disease
Prevalence of Sleep Disordered
Breathing in Cardiovascular Disease
• 30% of cardiac disease patients
– Schafer et al, Cardiology 1999
• 50% of heart failure patients
– Javaheri, Circulation 1998
• 40% pts with systolic HF
• 50% pts with diastolic HF
• 30% of hypertensive patients
– 83% of refractory hypertension
• Logan et al, J Hypertension 2001
Association Between
OSA & Hypertension
• 40- 60% of patients with HTN have OSA
2
– 85% of patients with Resistant Hypertension on 3 or more meds
have OSA
• Even mild OSA is a risk factor for hypertension
3, 6
• Patients with untreated OSA may be resistant to their anti-hypertensive
4
medications
• Even small decreases in blood pressure may help to decrease the risk of
5
heart attack and stroke
¹Silverberg, et al., Curr Hypertens R 2001
2 Kraicze, et al., AJRCCM 2000
3 Bixler, et al., Arch Intern Med 2000
4 Logan,
et al., J Hypertens 2001
et al., Circulation 2002
6 Neito, et al., Jama 2000
5 Heinrich,
New England Journal of Medicine,
2000
Peppard et al
• Recommendation by
Joint National
Committee on
Prevention,
Detection,
Evaluation and
Treatment of High
Blood Pressure (JNC
Hypertension Guidelines
7):
– Sleep Apnea listed
identifiable cause
of Hypertension
– All newly
diagnosed patients
should be screened
for Sleep Apnea
– All patients with
refractory
hypertension
should be screened
for Sleep Apnea
Chobanian, AV et al., J Hypertens 2003; 42: 12061252
Association Between
OSA & Heart Failure
• 37% of 450 HF patients had
OSA
– Also high incidence of Central or
Mixed apneas
• Risk factors for OSA in HF
included
– BMI > 35 in males
– Age > 60 in females
Work by Sin, et al., 2000
• The prevalence of
arrhythmias was compared
in two samples of
participants from the Sleep
Heart Health Study
– 228 subjects with sleepdisordered breathing
(RDI > 30) vs. 338
subjects without sleepdisordered breathing
(RDI < 5)
• Individuals with severe
sleep-disordered breathing
have two to fourfold higher
odds of complex
arrhythmias than those
without sleep-disordered
breathing even after
adjustment for potential
confounders.
Association Between
OSA & Arrhythmias
Shaded bar: pts with OSA
White bar: pts. without OSA
Mehra R, et.al. Am J of Respir Crit Care Med 2006 Vol. 173:
910-916
ACC/AHA HFSA Heart Failure Guidelines
• Recommendation by American
College of Cardiology,
American Heart Association
and the Heart Failure Society
of America :
– Sleep Apnea listed
identifiable cause of Heart
Failure
– It is recommended that all
newly diagnosed patients be
screened for Sleep Apnea
– Patients refractory to
treatment for Heart Failure
should be screened for
Sleep Apnea
Hunt, et.al. ACC/AHA 2005 Guidelines:
Circulation:2005:112
The Impact of Untreated
OSA on Cardiovascular
System
Cardiovascular mortality and morbidity in OSA
• Study of 1651 Men, over 10 years
–
–
–
–
264 Normal (control group)
377 Snorers (AHI<5)
403 Untreated Mild-Mod OSA (AHI 5 – 30 without EDS)
235 Untreated Severe OSA (AHI > 30 or AHI> 5 with
EDS)
– 372 Severe OSA with CPAP Treatment OSA (AHI > 30,
CPAP > 4hrs/day)
• CPAP compliance objectively measured
• Study Fatal and Non-Fatal Cardiac Events
Marin, JM et. al Lancet 2005: 365:1046 - 1053
Fatal CV Events over 10 year
period
Marin, JM et. al Lancet 2005: 365:1046 - 1053
Non-Fatal CV Events per group
Marin, JM et. al Lancet 2005: 365:1046 - 1053
Outcomes of Study
• Patients with severe OSA that was left
untreated had a significant increase in CV
events (both fatal or non-fatal events) after
10 years
– Risk factor: 2.87 higher than norms
• Patients with severe OSA had a significant
reduction in CV events when treated with
CPAP
– Patients who used CPAP > 4 hours per night
had a drop in CV risk
Marin, JM et. al Lancet 2005: 365:1046 - 1053
Treatment of OSA &
Refractory HTN
• 16 of 19 refractory HTN patients had underlying
OSA
• 11 patients participated in CPAP trial
• CPAP titrated to approx. 9 cm H20
• Blood pressure and baroreflex sensitivity were
studied on and off CPAP
• 24-hour blood pressure was evaluated at baseline
and after 2 months of CPAP therapy
Results:
• CPAP group: Approximate 10mmHg drop in mean blood
pressure
– predicts a 37% reduction in risk for CHD
– 56% reduction in risk for stroke
• No relevant change in blood pressure occurred with subtherapeutic CPAP
Screening in Hospital
• Sleep apnea is found in at least 50% of patients with
CHF
• Heart Failure nurses should screen for sleep apnea in
all CHF patients
• Referral to sleep disorder team
• Outpatient sleep study per MD order
All cardiac patients in outpatient Cardiology clinic should
be screened with Epworth Sleepiness tool
Results: Treatment of OSA &
Refractory HTN
Pre-CPAP
On CPAP
p value
AHI (hr-1 sleep)
45.3
±10.1
2.2
±0.5
<0.01
Arousal Index
(hr-1 sleep)
37.1
±5.9
9.4
±1.6
<0.001
Lowest SaO2 (%)
83.3
±1.1
92.1
±0.7
<0.0001
Population
Logan AG., et al., Eur Respir J 2003; 21: 241-247
Hallmark OSA Signs and
Symptoms
• Excessive daytime
sleepiness (EDS)
unexplained by other
factors
with
• Loud disruptive snoring
or
• Nocturnal
choking/gasping/snorting
or
• Nocturnal pauses in
breathing
Additional Signs/Symptoms of
OSA
• Recurrent nocturnal
awakenings
• Un-refreshing sleep
• Daytime fatigue
• Impaired
concentration/memory
loss
• Mood/behavioral
changes
• Morning headaches
• Loss of sexual interest
Pearls
• If person is on 3 antihypertensive
medications and still has high blood pressure, consider
a sleep study
• When a person has “congestive heart failure” due to
fluid buildup and their BNP is less than 120, screen for
sleep apnea
• Newly diagnosed CHF patients should be screened for
sleep apnea early
• Atrial fibrillation patients should be screened
• All cardiac patients should be screened when no other
known cause for cardiac condition
Suggestions for cardiac patients to
use CPAP/ BIPAP
• Use humidifier on CPAP to prevent dryness
• Nasal spray to open air passages
• Wear during naps to get used to mask and get a
boost of energy for rest of the day
• Encourage support from spouse/SO
• Give CPAP a friendly name
• Use at least 4 hours per night for benefit
Great News
•
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•
•
•
•
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Treatment can give people a new lease on life
More energy
Relieve headaches
Control blood pressure
Sleep all night
Less strain on the heart
Reduces cardiac events
Improve CHF symptoms
Sleep Trivia on Internet sites
• 3,150,000 sites for sleep apnea
• Oral Appliances that mold to your mouth
• Exercises to “cure” sleep apnea $19.99
Sleep tight