Obstructive Sleep Apnea

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2 Obstructive Sleep Apnea Definition: Repetitive episodes of upper airway obstruction (complete or partial) that occur during sleep and are associated with arousals or desaturations +/or daytime sleepiness. Results are reported as respiratory disturbance index or RDI 5-20 events/hour mild events/hour moderate > 40 events/hour severe

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5 Cardiovascular Effects of OSA Negative intrathoracic pressure Increased preload and afterload Reduced Stroke Volume Hypoxemia and hypercapnia Increased resp. drive & sympathetic tone Pulmonary vasoconstriction Systemic vasoconstriction Cardiac arrhythmias

6 Cardiovascular Effects of OSA Post Apnea Increased sympathetic tone Increased heart rate Increased blood pressure Repetitive Mueller maneuvers complicated by hypoxemia, hypercapnia, pulmonary vasoconstriction result in systemic hypertension and sleep deprivation.

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8 Morbidity of OSA Cardiac Arrhythmia/MI Systemic Hypertension Pulmonary Hypertension Sleep Fragmentation Impaired QOL Increased Mortality- both cardiac and MVA s (from decreased reaction time= DWI

9 HIPPA HIPPA HIPPA HIPPA HIPAA HIPPA HIPPA HIPPA

10 Epidemiology of OSA Young, et. al Prevalence % HTN Asthma SLE RA Sarcoid DM Insomnia RLS M RDI>5 W RDI>5 M RDI>5 + S W RDI>5 + S

11 Prospective Studies Nurses Health Study Began in 1976, 121,700 nurses ages RR of HTN and CVD 1.6 and 1.3 respectively for the snorer vs nonsnorer Adjusted for numerous confounders Wisconsin Sleep Cohort Study 5000 WI state employees, age yr f/u Logistic OR 1.8,3.0 for HTN if RDI 15,30 OR for CVD=3.0 if RDI>30

12 Sleep Heart Health Study N=6132 with 5 yr f/u PSG RDI>30, OR 1.5 for HTN Participants from several cardiovascular cohorts Adjusted for age, gender, BMI, race, smoking

13 CPAP The most effective treatment. Treats mild, moderate and severe OSA. >90% of patients will improve with CPAP during the first night of use. Long term compliance is 60-80%. Compliance is associated with education and perceived daytime sleepiness.

14 CPAP

15 CPAP and EF Naughton et al 95 studied 35 patients with EF~23% +/- one month of CPAP NO CPAP CPAP U Norepi (nmol/mmol creat) Plasma Norepi (nmol/l) Tkacova et al 97 studied 17 patients with EF~23% before and after 3 months of treatment with CPAP NO CPAP CPAP EF 21% 28% Pl Atrial Naturetic Factor pg/ml

16 Becker et al Circ 03 Investigated the role of CPAP on blood pressure. Methods: 32 patients with OSA randomized to therapeutic CPAP or subtherapeutic CPAP for ~ 9 weeks. Patient did not have to have HTN.

17 Becker et al Circ 03 mmhg MAP Systolic Diastolic CPAP Placebo

18 Kaneko et al NEJM 03 Investigated the effects of CPAP treatment for OSA on cardiac function. Methods: 32 patients with OSA and heart failure (avg EF ~ 27%) randomized to therapeutic CPAP or best medical management for ~ one month. *The patients did not have to be sleepy.

19 Kaneko et al NEJM 03

20 Kaneko et al NEJM 03

21 The Relationship Between CHF, Sleep Apnea and Mortality in Older Men. Ancoli-Israel Chest men from the medical wards at the VA San Diego Healthcare System. Sleep was recorded for 2 nights in the hospital. Follow-up occurred yearly until 2002.

22 Ancoli Israel: Chest, October 2003

23 Parish: Mayo Clin Proc August 2004

24 Yokoe: Circ, March 2003 C-reactive protein and interleukin (IL)-6 from 30 patients with OSA and 14 obese control subjects. The effects of 1 month of CPAP was then evaluated.

25 Yokoe: Circ, March 2003

26 Yokoe: Circ, March 2003

27 More Recent Data: PLoS Med 2009 Punjabi NM 6441 men & women in SHHS, adjusted for age sex, smoking, BMI, comorbids All cause mortality; Mod OSA (15-30) HR=1.17. >30 HR= yo men HR= 2.09! Circ 2010 Gottlieb DJ; Men % more likely to develop Coronary Heart Dx. Men AHI>30 58% more likely to get CHF. AJRCCM 2010 Redline, S; Stroke Men AHI>19 HR=2.86, women >25. Chest 2015 Cadby G; Afib w/ AHI>5 HR=1.55 So it s baseball, hot dogs, apple pie, Chevrolet and CPAP! Right?...

28 Effect of CPAP on hypertension CPAP reduces BP whether patient's are hypertensive or not CPAP augments meds so that combined therapy decrease his BP further The data is limited because most studies are comprised of patients with OSA & EDS. Decrease in BP is not associated with OSA severity

29 Effect of CPAP on hypertension Follow-up has been short Some studies added BP meds CPAP still more effective than O2 alone BP decreases more significantly with CPAP plus weight loss compared with either one alone Even small reduction in BP is significant but may not occur in patients with long-standing HTN or w/o EDS. There may be limited ability to reverse long-standing vascular disease so early and continued OSA treatment may be required for more effective preventive therapy.

30 CPAP and Afib Kanagala Circ 2003; CPAP reduced the rate of recurrent A. fib by almost half from 82% to 42% Fein AS JACC 2013; CPAP cause a higher A. fib free survival rate and A. fib free survival off antiarrhythmic drugs OSA is a potentially modifiable risk factor for A. fib

31 CPAP and Arrhythmia Eur Heart J 2004 Simantirakis EN group recorder monitored heart rhythm of 23 patient's for 16 months with moderate to severe OSA. Patient's were recorded for 2 months prior to CPAP and 14 months on CPAP. Bradycardia/asystole seen in 47% in the patient's prior to CPAP. Decreased after 8 weeks and none were detected in the last 6 months of CPAP. Thorax 2005 Ryan CM 58% reduction in PVCs on CPAP none in the control arm

32 CPAP and Sudden Death (the real kind, not OT!) NEJM 2005 Gami AS; 107 patient's on CPAP followed for 7 years. 7% of patient who stopped CPAP died compared to 0% to continued with CPAP JACC 2013 Gami AS; OSA severity and low O2 sat was associated with increased risk of sudden cardiac death

33 CPAP and Pulm HTN Many studies show a decrease in spap and PVR after 3-4 months. Eur Heart J 2006 Arias, MA; CPAP reduced PAS PE from mmhg and more dramatic in patients who had OSA + pulm htn.

34 It all seemed so simple until SAVE blew it! Large multicentered randomized control trials on the impact of CPAP on cardiovascular outcomes patient's with moderate to severe OSA randomized to CPAP plus usual care or usual care alone. Despite a decrease of AHI from 29-4 there was no significant reduction in cardiac events (CV deaths, MI s, stroke, CHF, hospitalizations, angina, TIA) The rate of cardiovascular events was slightly improved in patients who were CPAP for more than 4 hours but not statistically significant

35 SAVE: Important exclusions Sleepy OSA patients Patients at risk of a car accident Severe hypoxemia Used automated home studies for diagnosis and an overall low CPAP compliance avg 3.3 hours per night There are other studies that throw cold water on CPAP therapy but may be a sample size issue or duration of the study to detect cardiovascular benefit

36 After SAVE; Now what? Compliance with CPAP is certainly an issue This is nothing new to caregivers who treat patients with sleep apnea If patient's feel better on CPAP there will be more likely to use it. Like any other therapy if they're more likely to use it more likely benefit from it. A study that shows CPAP use for less than 4 hours did not show a positive benefit is not that surprising to me at all I suspect the field of sleep medicine and industry will come through with more definitive data

37 SUMMARY Epidemiologic data to support an association between OSA and CVD. Physiologic data that demonstrates a link. Positive pressure has been used in ICU s for years to treat patients with CHF. Now more comfortable non-invasive modality for stable outpatients.

38 SUMMARY Good data to support treatment- reverses negative effects. Relatively inexpensive when compared with other modalities. (All the benefits of a beta-blocker without the impotence! In fact, improves libido.) Need to ask the questions! Won t recognize OSA unless you do. (~ guessing BP) DO YOU SNORE? IS YOUR SLEEP REFRESHING?

39 CONCLUSION Sleep disturbances have huge medical implications. Snoring, although common, is ABNORMAL and should be investigated further. Problem getting worse due to obesity. WE CANNOT AFFORD NOT TO TREAT SLEEP APNEA!

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