Sleep Apnea in the Sleep Apnea in the Cardiac PatientCardiac Patient

Stephen JennisonStephen Jennison

What is the impact of Sleep What is the impact of Sleep apnea on cardiovascular apnea on cardiovascular

disease?disease?• Which came first: sleep apnea or CV Which came first: sleep apnea or CV

disease?disease?• More research is needed per AHA and More research is needed per AHA and

ACCACC• Difficult to decide impact due to multiple Difficult to decide impact due to multiple

co-co-

morbidities of obesity, diabetes and morbidities of obesity, diabetes and metabolic syndromemetabolic syndrome

SDB Impact on the SDB Impact on the Cardiovascular SystemCardiovascular System

• Both OSA & CSA occur Both OSA & CSA occur commonly in patients with commonly in patients with cardiovascular disease and HF cardiovascular disease and HF and may contribute to disease and may contribute to disease progression.progression.

Parasympathetic

Constrict bronchioles

Slow down heartbeat

Increase secretion

Increase motility

Empty colon

Empty bladder

Stop secretion

Sympathetic

Dilate bronchioles

Speed up heartbeat

Secrete adrenaline

Decrease secretion

Decrease motility

Retain colon contents

Delay emptying

Constrict

Secrete saliva

Dilate

gland

Stomach

Bladder

Spinalcord

Sympatheticganglionchain

Parasympathetic

Parasympathetic

Adrenal

Sympathetic Sympathetic ActivationActivation

Wakefulness

Sleep Arousal & Hyperventilation O2 & CO2

Sympathetic Activation

Airway Patency Compensation

Airway Collapse

Decreased Compensation

O2 & CO2

Increased RR

Increased mental activity

Increased BP HR Increased

Increased release of glucose

OSA Impacts: OSA Impacts: Sympathetic Nerve Activity, Sympathetic Nerve Activity, Blood Pressure, Oxygenation Blood Pressure, Oxygenation

etc.etc.

OSA OSA OSA

250

125

0

BP

RESP

Sympathetic Nerve Activity

Somers VK et al. J Clin Invest. 1995;96:1897.

Studies Linking OSA and Studies Linking OSA and Cardiovascular DiseaseCardiovascular Disease

Prevalence of Sleep Prevalence of Sleep Disordered Breathing in Disordered Breathing in Cardiovascular DiseaseCardiovascular Disease

• 30% of cardiac disease 30% of cardiac disease patientspatients– Schafer et al, Cardiology 1999Schafer et al, Cardiology 1999

• 50% of heart failure patients50% of heart failure patients– Javaheri, Circulation 1998Javaheri, Circulation 1998

• 40% pts with systolic HF 40% pts with systolic HF • 50% pts with diastolic HF50% pts with diastolic HF

• 30% of hypertensive patients30% of hypertensive patients– 83% of refractory hypertension83% of refractory hypertension

• Logan et al, J Hypertension 2001Logan et al, J Hypertension 2001

• 40- 60% of patients with HTN have OSA40- 60% of patients with HTN have OSA22

– 85% of patients with Resistant Hypertension on 3 or 85% of patients with Resistant Hypertension on 3 or more meds have OSAmore meds have OSA

• Even mild OSA is a risk factor for hypertensionEven mild OSA is a risk factor for hypertension3, 63, 6

• Patients with untreated OSA may be resistant to their Patients with untreated OSA may be resistant to their anti-hypertensive medicationsanti-hypertensive medications44

• Even small decreases in blood pressure may help to Even small decreases in blood pressure may help to decrease the risk of heart attack and strokedecrease the risk of heart attack and stroke55

¹Silverberg, et al., Curr Hypertens R 20012 Kraicze, et al., AJRCCM 20003 Bixler, et al., Arch Intern Med 2000

4 Logan, et al., J Hypertens 20015 Heinrich, et al., Circulation 20026 Neito, et al., Jama 2000

Association BetweenAssociation BetweenOSA & HypertensionOSA & Hypertension

New England Journal of New England Journal of Medicine, 2000Medicine, 2000

Peppard Peppard et alet al

Hypertension Hypertension GuidelinesGuidelines

• Recommendation Recommendation by Joint National by Joint National Committee on Committee on Prevention, Prevention, Detection, Detection, Evaluation and Evaluation and Treatment of High Treatment of High Blood Pressure Blood Pressure (JNC 7):(JNC 7):

– Sleep Apnea Sleep Apnea listed listed identifiable identifiable cause of cause of HypertensionHypertension

– All newly All newly diagnosed diagnosed patients should patients should be screened for be screened for Sleep ApneaSleep Apnea

– All patients with All patients with refractory refractory hypertension hypertension should be should be screened for screened for Sleep ApneaSleep Apnea

Chobanian, AV et al., J Hypertens Chobanian, AV et al., J Hypertens 2003; 42: 1206-12522003; 42: 1206-1252

Association BetweenAssociation Between

OSA & Heart OSA & Heart FailureFailure

• 37% of 450 HF patients had 37% of 450 HF patients had OSAOSA– Also high incidence of Central or Also high incidence of Central or

Mixed apneasMixed apneas

• Risk factors for OSA in HF Risk factors for OSA in HF includedincluded– BMI > 35 in malesBMI > 35 in males– Age > 60 in femalesAge > 60 in females

Sin et.al, Am J Respir Crit Care Med 1999; 160: Sin et.al, Am J Respir Crit Care Med 1999; 160: 1101-11061101-1106

Work by Sin, et al., 2000

• The prevalence of The prevalence of arrhythmias was arrhythmias was compared in two compared in two samples of participants samples of participants from the Sleep Heart from the Sleep Heart Health Study Health Study – 228 subjects with 228 subjects with

sleep-disordered sleep-disordered breathing (RDI > 30) breathing (RDI > 30) vs. 338 subjects vs. 338 subjects without sleep-without sleep-disordered breathing disordered breathing (RDI < 5)(RDI < 5)

• Individuals with severe Individuals with severe sleep-disordered sleep-disordered breathing have two to breathing have two to fourfold higher odds of fourfold higher odds of complex arrhythmias complex arrhythmias than those without than those without sleep-disordered sleep-disordered breathing even after breathing even after adjustment for potential adjustment for potential confounders. confounders.

Association Association BetweenBetweenOSA & OSA &

ArrhythmiasArrhythmias

Mehra R, et.al. Am J of Respir Crit Care Med 2006 Vol. 173: 910-916

Shaded bar: pts with OSAWhite bar: pts. without OSA

ACC/AHA HFSA Heart Failure ACC/AHA HFSA Heart Failure GuidelinesGuidelines• Recommendation by Recommendation by

American College of American College of Cardiology, American Heart Cardiology, American Heart Association and the Heart Association and the Heart Failure Society of America :Failure Society of America :– Sleep Apnea listed Sleep Apnea listed

identifiable cause of identifiable cause of Heart FailureHeart Failure

– It is recommended that It is recommended that all newly diagnosed all newly diagnosed patients be screened for patients be screened for Sleep ApneaSleep Apnea

– Patients refractory to Patients refractory to treatment for Heart treatment for Heart Failure should be Failure should be screened for Sleep Apneascreened for Sleep Apnea

Hunt, et.al. ACC/AHA 2005 Guidelines: Circulation:2005:112

The Impact of The Impact of Untreated OSA on Untreated OSA on

Cardiovascular Cardiovascular System System

Cardiovascular mortality and morbidity in OSA

• Study of 1651 Men, over 10 yearsStudy of 1651 Men, over 10 years– 264 Normal (control group) 264 Normal (control group) – 377 Snorers (AHI<5)377 Snorers (AHI<5)– 403 Untreated Mild-Mod OSA (AHI 5 – 30 403 Untreated Mild-Mod OSA (AHI 5 – 30

without EDS) without EDS) – 235 Untreated Severe OSA (AHI > 30 or 235 Untreated Severe OSA (AHI > 30 or

AHI> 5 with EDS)AHI> 5 with EDS)– 372 Severe OSA with CPAP Treatment OSA 372 Severe OSA with CPAP Treatment OSA

(AHI > 30, CPAP > 4hrs/day)(AHI > 30, CPAP > 4hrs/day)

• CPAP compliance objectively measuredCPAP compliance objectively measured• Study Study FatalFatal and and Non-Fatal Cardiac Non-Fatal Cardiac

EventsEvents Marin, JM et. al Lancet 2005: 365:1046 - 1053

Fatal CV Events over 10 Fatal CV Events over 10 year periodyear period

Marin, JM et. al Lancet 2005: 365:1046 - 1053

Non-Fatal CV Events per Non-Fatal CV Events per groupgroup

Marin, JM et. al Lancet 2005: 365:1046 - 1053

Outcomes of StudyOutcomes of Study• Patients with severe OSA that Patients with severe OSA that

was left untreated had a was left untreated had a significant increase in CV events significant increase in CV events (both fatal or non-fatal events) (both fatal or non-fatal events) after 10 years after 10 years – Risk factor: 2.87 higher than normsRisk factor: 2.87 higher than norms

• Patients with severe OSA had a Patients with severe OSA had a significant reduction in CV significant reduction in CV events when treated with CPAPevents when treated with CPAP– Patients who used CPAP > 4 hours Patients who used CPAP > 4 hours

per night had a drop in CV riskper night had a drop in CV riskMarin, JM et. al Lancet 2005: 365:1046 - 1053

Treatment of OSA & Treatment of OSA & Refractory HTN Refractory HTN

• 16 of 19 refractory HTN patients had 16 of 19 refractory HTN patients had underlying OSA underlying OSA

• 11 patients participated in CPAP trial11 patients participated in CPAP trial

• CPAP titrated to approx. 9 cm HCPAP titrated to approx. 9 cm H2200

• Blood pressure and baroreflex sensitivity Blood pressure and baroreflex sensitivity were studied on and off CPAPwere studied on and off CPAP

• 24-hour24-hour blood pressure was evaluated at blood pressure was evaluated at baseline and after 2 months of CPAP baseline and after 2 months of CPAP therapytherapy

• Logan AG., et al., Eur Respir J 2003; 21: 241-247Logan AG., et al., Eur Respir J 2003; 21: 241-247

Results:Results: • CPAP group: Approximate 10mmHg drop in CPAP group: Approximate 10mmHg drop in

mean blood pressuremean blood pressure– predicts a 37% reduction in risk for CHDpredicts a 37% reduction in risk for CHD – 56% reduction in risk for stroke56% reduction in risk for stroke

• No relevant change in blood pressure occurred No relevant change in blood pressure occurred with sub-therapeutic CPAPwith sub-therapeutic CPAP

Screening in HospitalScreening in Hospital

• Sleep apnea is found in at least 50% of Sleep apnea is found in at least 50% of patients with CHFpatients with CHF

• Heart Failure nurses should screen for Heart Failure nurses should screen for sleep apnea in all CHF patients sleep apnea in all CHF patients

• Referral to sleep disorder teamReferral to sleep disorder team• Outpatient sleep study per MD orderOutpatient sleep study per MD order

All cardiac patients in outpatient All cardiac patients in outpatient Cardiology clinic should be screened with Cardiology clinic should be screened with Epworth Sleepiness toolEpworth Sleepiness tool

Results: Treatment of Results: Treatment of OSA & Refractory HTNOSA & Refractory HTN

PopulatioPopulationn

Pre-Pre-CPAPCPAP

On CPAPOn CPAP p valuep value

AHI (hrAHI (hr-1-1 sleep)sleep)

45.345.3±10.1±10.1

2.22.2±0.5±0.5

<0.01<0.01

Arousal Index Arousal Index (hr(hr-1-1 sleep) sleep)

37.137.1±5.9±5.9

9.49.4±1.6±1.6

<0.001<0.001

Lowest SaOLowest SaO22

(%)(%)83.383.3±1.1±1.1

92.192.1±0.7±0.7

<0.0001<0.0001

Logan AG., et al., Eur Respir J 2003; 21: 241-247

Hallmark OSA Signs Hallmark OSA Signs and Symptomsand Symptoms

• Excessive daytime Excessive daytime sleepiness (EDS) sleepiness (EDS) unexplained by other unexplained by other factors factors

with with • Loud disruptive Loud disruptive

snoringsnoring oror

• Nocturnal Nocturnal choking/gasping/snochoking/gasping/snortingrting

oror• Nocturnal pauses in Nocturnal pauses in

breathingbreathing

Additional Additional Signs/Symptoms of OSASigns/Symptoms of OSA• Recurrent nocturnal Recurrent nocturnal

awakeningsawakenings• Un-refreshing sleepUn-refreshing sleep• Daytime fatigueDaytime fatigue• Impaired Impaired

concentration/memconcentration/memory lossory loss

• Mood/behavioral Mood/behavioral changeschanges

• Morning headachesMorning headaches• Loss of sexual Loss of sexual

interestinterest

PearlsPearls

• If person is on 3 antihypertensive If person is on 3 antihypertensive medications and still has high blood medications and still has high blood pressure, consider a sleep studypressure, consider a sleep study

• When a person has “congestive heart When a person has “congestive heart failure” due to fluid buildup and their BNP is failure” due to fluid buildup and their BNP is less than 120, screen for sleep apnealess than 120, screen for sleep apnea

• Newly diagnosed CHF patients should be Newly diagnosed CHF patients should be screened for sleep apnea early screened for sleep apnea early

• Atrial fibrillation patients should be Atrial fibrillation patients should be screenedscreened

• All cardiac patients should be screened All cardiac patients should be screened when no other known cause for cardiac when no other known cause for cardiac conditioncondition

Suggestions for cardiac Suggestions for cardiac patients to use CPAP/ patients to use CPAP/

BIPAPBIPAP• Use humidifier on CPAP to prevent Use humidifier on CPAP to prevent

dryness dryness • Nasal spray to open air passages Nasal spray to open air passages • Wear during naps to get used to Wear during naps to get used to

mask and get a boost of energy for mask and get a boost of energy for rest of the dayrest of the day

• Encourage support from spouse/SOEncourage support from spouse/SO• Give CPAP a friendly nameGive CPAP a friendly name• Use at least 4 hours per night for Use at least 4 hours per night for

benefitbenefit

Great NewsGreat News

• Treatment can give people a new Treatment can give people a new lease on lifelease on life

• More energyMore energy• Relieve headachesRelieve headaches• Control blood pressureControl blood pressure• Sleep all night Sleep all night • Less strain on the heartLess strain on the heart• Reduces cardiac eventsReduces cardiac events• Improve CHF symptomsImprove CHF symptoms

Sleep Trivia on Internet Sleep Trivia on Internet sitessites

• 3,150,000 sites for sleep apnea3,150,000 sites for sleep apnea• Oral Appliances that mold to your Oral Appliances that mold to your

mouthmouth• Exercises to “cure” sleep apnea Exercises to “cure” sleep apnea

$19.99$19.99

Sleep tight