Sleep and Cardiovascular Disease KD Weeks, MD, FACC, FAASM
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No disclosures to report
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Impact of Cardiovascular Disorders 900,000 deaths per year in
USA Hypertension alone affects 75 million Americans, many
misdiagnosed as essential Research has discovered evidence of
bidirectional relationship of sleep apnea and c-v disorders
Mechanisms: Arousals > neuro-hormonal activation > release of
inflammatory mediators (cytokines) and adhesion molecules >
reactive oxygen species and transcription factors due to oxidative
stress Javaheri Principles and Practice of Sleep Medicine 2004
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Web Traffic to www.acc.org Subsite on Sleep Apnea and Heart
Failurewww.acc.org
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Possible C-V Complications of OSA Endothelial dysfunction
Hypertension Pulmonary hypertension Systolic or diastolic heart
failure Arrhythmias Coronary artery disease TIA and stroke Dementia
Death
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Impact of Therapy Treatment of obstructive and central sleep
apnea with PAP results in improvement of c-v morbidity and
mortality Unclear whether OSA treatment reduces risk of sudden
cardiac death Fanari ACC-Cardiosource 2014
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Hypertension and OSA Known for decades but difficulty proving
causal relationship and benefit of CPAP therapy Severity of OSA at
baseline impacts future onset of hypertension (Wisconsin Sleep
Cohort) Small but significant reduction in daytime blood pressure
in normotensive patients after four weeks of PAP therapy Refractory
hypertension, eg 3 drugs at maximum dose with persistent
hypertensive pressure elevations, is associated with OSA in 83% of
patients Non-sleepy patients with OSA may be immune to the bp
lowering effect of therapy
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Sleep Apnea and Stroke Chronic intermittent hypoxia is a key
factor in vascular inflammation, atherosclerosis, and endothelial
disease Cycle of inflammation Rise in sympathetic activity and
blood pressure amplify the effect of the cycle of inflammation
Impact of atrial fibrillation and patent foramen ovale also
contributes to the risk of embolic stroke
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Javaheri 2007 Sleep Medicine Clinics
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Sleep Disordered Breathing and Atrial Fib New data on
mechanisms and impact: Upper airway collapse > hypoxia >
ventilator overshoot > hypercapnia > autonomic instability
and intrathoracic pressure alterations Increased state of
thrombosis, inflammation, and oxidative stress produce a
pro-arhythmogenic milieu, atrial macro-reentry, and automaticity
OSA is a powerful predictor of ablation failure, independent of
atrial enlargement, obesity, or hypertension A fib will affect up
to 16 million patients by 2050 A fib will cost $6.7 billion per
year In a cardiology practice the majority of OSA patients have
been referred by electrophysiologists Future strategies? Mehra
ACC-Cardiosource 2014
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Pulmonary Hypertension (PAH) and Sleep Apnea OSA recognized by
WHO in 1998 as a secondary cause of PAH 15 70% of OSA patients have
PAH COR pulmonale may occur in cases of severe OSA, especially if
associated with high PaCO 2 Several but not all studies show
compliant, effective treatment of OSA improves PAH
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Obstructive and Central OSA and Heart Failure HF R EF HF P EF
Major public health issue High mortality and morbidity Frequent
hospital admissions and readmissions High economic impact
Obstructive sleep apnea is the most common, least recognized
co-morbidity -- 70% of HF patients have OSA/CSA Similar symptoms in
heart failure and OSA CSA associated with higher mortality PAP may
not improve mortality in HF patients
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Obstructive and Central OSA and Heart Failure HF R EF HF P EF
(contd) CSA is suppressed in 50% of HF patients by CPAP In HF
patients OSA is not associated with daytime sleepiness ASV is
recommended for CPAP non-responders with CSA
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Meddic.jp
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Coronary Heart Disease and Sleep Apnea CAD estimated to be
present in 20 25% of OSA patients Prevalence is 30% in case
controlled studies with an independent association Direct causality
is not well established Major cardiac events are more likely in
patients with severe OSA CPAP may significantly reduce c-v events
AHI severity is an independent predicator of mortality in patients
with CAD Screening for both disorders in patients with risk factors
for one is suggested as well as co-management strategies Impaired
sleep in men and disturbed sleep in women may be related to
moderately higher risk of poor cardiac prognosis after first AMI
(A. Clark SLEEP2014)
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Patent Foramen Ovale and Sleep Apnea Congenital cardiac defect
present in approximately 25% of healthy adults and usually
asymptomatic Patients with PFO might have left to right shunt which
can lead to systemic embolization It is little known and poorly
studied Severe OSA may raise the risk of complications in patients
with elevated right heart pressures
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Amplatzer PFO Occluder
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Gore Helex PFO Occluder
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Patent Foramen Ovale and Sleep Apnea Questions 1.Do patients
with severe OSA have a higher prevalence of PFO compared to healthy
individuals? 2.Does PFO combined with OSA result in higher stroke
risk? 3.Does percutaneous PFO closure improve OSA symptoms?
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Insomnia and C-V Disease Risk 20% of US adults are affected by
insomnia but only 10% are chronic Death mechanism is unclear but
inflammation due to stress can be measured by C-reactive protein
which is associated with cardiovascular risk One 38 year study of
1,409 adults concluded that persistent but not intermittent
insomnia was associated with increased all-cause and
cardiopulmonary mortality, and a steeper increase in inflammatory
markers (S. Parthasarathy American Journal of Medicine 2014)
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Punjabi NM PLoS Med2009
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Sleep Disorders and Mortality Many prospective long term
studies suggest that untreated patients with OSA have higher risk
of death from all causes, particularly cardiovascular There is a
relationship between severity of the OSA and cardiovascular risk
OSA predicts incident sudden cardiac death and the risk magnitude
is predicted by multiple parameters characterizing OSA severity,
independent of established risk factors Therapy with effective
compliant PAP significantly reduces mortality from c-v disease and
auto accidents
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Sleep Apnea and the Association with Cancer Peppard PE; Nieto
FJ. Here come the sleep apnea-cancer studies. SLEEP
2013;36(10):1409-1411.
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Sleep and Cardiovascular Disease KD Weeks, MD, FACC, FAASM
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Graphics Permissions Slide 2: Creative Commons Attribution
License by Chris Potter on www.stockmonkey.com Slide 4: American
College of Cardiology Slide 7: 2015 Kenneth D. Weeks, Jr., MD Slide
9: Public Domain image by the National Heart Lung and Blood
Institute (NIH) on Wikimedia Commons Slide 11: 2007 Shahrokh
Javaheri, MD Slide 12: 2015 Kenneth D. Weeks, Jr., MD Slide 15:
2007 Shahrokh Javaheri, MD Slide 20: Creative Commons
Attribution-NonCommercial 2.0 Generic. Some rights reserved by
HeartBabyHome. Adapted with permission by cropping and resizing.
Slide 22: 2006 W. L. Gore & Associates, Inc. Slide 23: Crown
Copyright by Capital & Coast District Health Board, New Zealand
Slide 24: 2006 W. L. Gore & Associates, Inc. Slide 25: 2006 W.
L. Gore & Associates, Inc. Slide 28: Creative Commons
Attribution License by Punjabi et al. PLoS Med 2009 August.