Presentation on theme: "Sleep Apnea and Cardiovascular Disease"— Presentation transcript:
1 Sleep Apnea and Cardiovascular Disease Mohammed Fakhry AbdulMohsen, MD, FACCAssociate Professor and Consultant Internist/CardiologistUniversity of Dammam andKing Fahd Hospital of the University.
2 Sleep Apnea and Cardiovascular Disease Sleep-related breathing disorders are highly prevalent in patients with established cardiovascular disease.Obstructive Sleep Apnea (OSA) affects adult Americans and is present in large number of patients with HTN and other CVD such as CAD, Stroke and AF.Central Sleep Apnea (CSA) occurs mainly in patients with Heart Failure (HF)
3 Sleep Apnea and Cardiovascular Disease Objectives:To describe the types and prevalence of SA and its relevance to individuals who are at risk for or already have established CVD.To help develop the platform from which with the collaboration with specialist in sleep medicine and related disciplines, such consensus may develop.
9 Sleep Apnea and Cardiovascular Disease Table 1.Definitions of Terms (5)Apnea:Cessation of airflow for 10 sHypopnea:A reduction in but not complete cessation of airflow to 50% of normal,usually in association with a reduction in oxyhemoglobin saturationAHI:The frequency of apneas and hypopneas per hour of sleep; a measure ofthe severity of sleep apneaOSA and hypopnea:Apnea or hypopnea resulting from complete or partial collapse,respectively, of the pharynx during sleep
10 Sleep Apnea and Cardiovascular Disease Table 1.Definitions of Terms (5)CSA and hypopnea:Apnea or hypopnea resulting from complete or partial withdrawal ofcentral respiratory drive to the muscles of respiration duringsleepOxygen desaturation:Reduction in oxyhemoglobin saturation, usually as a result of an apnea orhypopneaSleep apnea syndrome:At least 10 to 15 apneas and hypopneas per hour of sleep associated withsymptoms of sleep apnea, including loud snoring, restless sleep, nocturnaldyspnea, headaches in the morning, and excessive daytime sleepiness
11 Sleep Apnea and Cardiovascular Disease Table 1. (Cont’d)Polysomnography:Multichannel electrophysiological recording ofelectroencephalographic, electrooculographic, electromyographic,ECG, and respiratory activity to detect disturbance of breathingduring sleepNREM sleep:Non–rapid eye movement or quiet sleepREM sleep:Rapid eye movement or active sleep; associated with skeletalmuscle atonia, rapid movements of the eyes, and dreamingArousal: Transient awakening from sleep lasting 10 s
12 Sleep Apnea and Cardiovascular Disease Table 2:Obstructive Sleep Apnea Signs, symptoms, and risk factors:- Disruptive snoring- Witnessed apnea or gasping- Obesity and/or enlarged neck size- Hypersomnolence- Other signs and symptoms include male gender,crowded-appearing pharyngeal airway, HTN, morningheadache, sexual dysfunction, behavioral changes(especially in children)
13 Sleep Apnea and Cardiovascular Disease Screening and diagnostic tests- Questionnaires- Holter monitoring- Overnight oximetry- Home-based/ambulatory unattended polysomnography- In-hospital attended overnight polysomnography.Treatment options:- Positional therapy- Weight loss- Avoidance of alcohol and sedatives- Positive airway pressure- Oral appliances
14 Sleep Apnea and Cardiovascular Disease Table 3:Central Sleep Apnea (CSA) Signs, symptoms, and risk factors:Congestive heart failureParoxysmal nocturnal dyspneaWitnessed apnea Fatigue/hypersomnolenceOther signs and symptoms include male gender, older age, mitral regurgitation, atrial fibrillation, Cheyne Stokes Respiration (CSR) while awake, hyperventilation with hypocapnia
15 Central Sleep Apnea In HF Figure 2. Schematic outlining possible mechanisms underlying development ofCSA and the possible feedback from CSA resulting in exacerbation of heartfailure.
16 Sleep Apnea and Cardiovascular Disease Table 3:Central Sleep Apnea (CSA):Screening and diagnostic tests:Overnight oximetryAmbulatory (unattended) polysomnographyIn-hospital (attended) polysomnographyTreatment options:Optimize treatment of heart failurePositive airway pressureSupplemental oxygen
17 Sleep Apnea and Cardiovascular Disease OSA and Cardiovascular disease:There is a clear association between OSA and cardiovascular diseaseHigher incidence of adverse cardiovascular events in untreated patients with OSAPostgrad Med J 2008; 84:15-22SLEEP 2007;30(3):CHEST 2008; 133:Proc Am Thorac Soc 2008; 5:
18 Sleep Apnea and Cardiovascular Disease Postgrad Med J 2008; 84:15-22
21 OSA and Hypertension, Why does it happen? OSA can lead to hypoxia (low oxygen levels), repetitive changes in oxygen saturations, and large swings in intrathoracic pressuresThese changes are detected by receptors in the brain and in the periphery (carotid bodies)Stimulate a sympathetic response (“fight or flight response”, “stress” response) increased heart rate and blood pressurePostgrad Med J 2008; 84:15-22
22 OSA and Hypertension Why does it happen? Repeated stimulation increased sympathetic tone during the day High blood pressureStudies have showed:Increased tonic chemoreflex driveAbnormalities in HR and BP variabilities during normal awake hours in patients with OSAPostgrad Med J 2008; 84:15-22
23 OSA and Hypertension Some Numbers Wisconsin prospective sleep cohort (2000)709 patients with OSARisk of developing HTN over 4 years:Minimal OSA: 1.42 x normalMild-moderate: 2.03 x normalModerate-severe: 2.89 x normalAfter adjusting for other risk factors
24 OSA and Hypertension Some Numbers ~40% of people with OSA have HTN while awake40-80% of people with non-controlled HTN have OSA
26 OSA and Hypertension How to treat it? Effective CPAP therapy can reduce BPOne study showed a fall in systolic BP by 10 mmHg after 4 weeks of CPAPImprovement in blood pressure correlated with improvement in sleepiness
28 OSA and Heart AttacksPeople with sleep disordered breathing (SDB) have a high prevalence of coronary heart disease (CHD)People with CHD have a high prevalence of SDB
29 OSA and Heart Attacks: Why does it Happen? Multiple nightly stresses on the heart:Repetitive fluctuations in oxygen levelsIncreased blood pressure surgesHigh sympathetic nervous system tone
30 OSA and Heart Attacks Marin et al. 2005 10 year follow-up study looking at CV events and OSA (including heart attacks and strokes)Included 264 healthy men, 377 snorers, 403 untreated mild-mod OSA, 235 untreated severe OSA and 372 treated with CPAP
32 OSA and Heart AttacksGami et al. looked at 112 patients who underwent a sleep studyFollowed them for 5 yearsSudden death from cardiac causes (between midnight and 6 am) occurred in 46% of pts with OSA vs 16% of general population
34 OSA and Heart FailureCSA is the SDB most commonly associated with HF. Javaheri 2006→ 49% with CHF have SDB (37% CSA, 12% OSA)Heart Failure is 2.38 x more common in “mild-moderate OSA” than in “no OSA”Postgrad Med J 2008; 84:15-22
35 OSA and Heart Failure: Why does it happen? HypertensionLeft ventricular diastolic dysfunctionAtrial fibrillationCHEST 2008; 133:793–804
36 OSA and Heart Failure: Effect of treatment 2 randomized studies of CPAP for OSA in CHF, showed some improvement in EF over 1-3 monthsEffect of CPAP treatment on mortality/morbidity from heart failure is unknownCHEST 2008; 133:793–804
39 OSA and Cardiac Arrhythmias Abnormal heart rhythms have been associated with OSA1983 Guilleminault et al.:400 pts with OSA48% had cardiac arrhythmias at night2% sustained VT, 11% sinus arrest, 8% AV block, 19% PVCPostgrad Med J 2008; 84:15-22
40 OSA and Cardiac Arrhythmias; Atrial Fibrillation: Four times increased risk of AF in pts with OSA (AHI>30) (Sleep Heart Health Study 2006)Onset of >75% of persistent A fib episodes in pts with OSA occur at night (8pm-8am)A fib recurrence after cardioversion twice as high in untreated OSAObservational review over 17 yrs suggests that nocturnal hypoxemia influences the onset of A fibPostgrad Med J 2008; 84:15-22Proc Am Thorac Soc 2008; 5:
41 OSA and Cardiac Arrhythmias; Ventricular Arrhythmias: Reported in pts with OSACausative role not provenNEJM 2005, a study observed higher incidence of sudden death during night hours (12am-6am) in pts with OSA, suggesting but not proving a causative effectProc Am Thorac Soc 2008; 5:
44 OSA and Strokes OSA is a risk factor for stroke 2 prospective cohort studies following 1022 and 1651 pts found a higher incidence of stroke in OSASLEEP, Vol. 30, No. 3, 2007
45 OSA and Strokes: Why does it happen? Increased CRP (inflammation) and atherogenesisIncreased thrombotic risks (clotting of blood)Increased blood pressureHypoxiaTheoretically PFO?SLEEP, Vol. 30, No. 3, 2007
46 OSA and Strokes; Treatment effect: No randomized controlled trialsObservational studies are controversial on whether treatment of OSA would prevent strokes or notSLEEP, Vol. 30, No. 3, 2007
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