GOALS. Obstructive Sleep Apnea and Cardiovascular Disease (OVERVIEW) FINANCIAL DISCLOSURE 2/1/2017

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1 Obstructive Sleep Apnea and Cardiovascular Disease (OVERVIEW) 19th Annual Topics in Cardiovascular Care Steven Khov, DO, FAAP Pulmonary Associates of Lancaster, Ltd February 3, 2017 FINANCIAL DISCLOSURE NONE The speaker has no financial or other conflicts of interest to report GOALS What is Obstructive Sleep Apnea? What are the Risk Factors? What are the cardiac health effects of OSA? Testing for OSA? Treatments for OSA Put people to sleep during this talk 1

2 Obstructive Sleep Apnea Obstructive sleep apnea (OSA) is a disorder in which a person frequently stops breathing during his or her sleep. 1 It results from an obstruction of the upper airway during sleep that occurs because of inadequate motor tone of the tongue and/or airway dilator muscles John G Park, Kannan Ramar, Eric Olson. Updates on Definition, Consequences, and Management of Obstructive Sleep Apnea. Mayo Clin Proc Jun; 86(6): Image Credit: drkarennation.com Prevalence of OSA afflicts at least 25 million adults in the U.S 2 estimated 26% of adults between ages have sleep apnea 2 BMI greater than 28, OSA is present in 41% 3 Up to 93% of women and 82% of men with moderate to severe OSA are not diagnosed 4 2. Peppard PE, et al. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol 2013 May 1;177(9): Vgontzas AN, et al. Sleep apnea and sleep disruption in obese patients. Arch Intern Med. 1994;154: Young, T., et al. Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women. Sleep. 1997;20:

3 Cardiovascular Effects of OSA Hypertension 3- to 4-fold increase risks of complex tachyarrhythmia (afib and NSVT) higher recurrence rate of atrial fibrillation increased the odds of fatal and nonfatal cardiovascular events higher incidence of stroke, independent of confounders Increase risk of having heart failure (odds ratio 2.38) Shahar E., et al. Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med 2001; 163:19 25 Symptoms of OSA RISK FACTORS Male Gender Obesity (BMI >30) Hypertension Alcohol or sedative usage Upper Airway/Facial Abnormalities Smoking Large Neck Circumference (>17 male, >16 female) Family History of OSA Endocrine and/or metabolic disorders 3

4 Shared Risk Factors Hypertension Higher incidents in men Increase incidence with age Increase risks with increase BMI Sedentary lifestyle Dietary indiscretions Hypertension and OSA Wisconsin Sleep Cohort Study Prospective Population Based Study Adjusted for baseline hypertension, BMI, neck and waist circumference, age, sex, and use of alcohol and cigarettes dose response association between sleep-disordered breathing at base line and the presence of hypertension four years later that was independent of known confounding factors >15 Odds Ratio % CI Treatment of OSA with CPAP improved blood pressure control, even in those with resistant hypertension 6 5. Peppard, SE et al., Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med. 2000;342: Dernaika TA et al., Effects of nocturnal continuous positive airway pressure therapy in patients with resistant hypertension and obstructive sleep apnea. J Clin Sleep Med. 2009;5:

5 OSA and AFib 7 Mayo Clinic % higher incident of OSA found in patients with persistent Afib 8 German study 2009 OSA prevalence 42.7% 9 Brazil study 2009 OSA prevalence 81.6% 7. Gami AS. et al., Association of atrial fibrillation and obstructive sleep apnea. Circulation 2004;110: Bitter T. et al., Sleep-disordered breathing in patients with atrial fibrillation an normal systolic left ventricular function. Dtsch Arztebl Int. 2009;106: Braga B. et al., Sleep disordered breathing and chronic atrial fibrillation. Sleep Med. 2009;10: OSA and recurrence rate Afib Untreated OSA recurrence rate of Afib at 12 months was 82% Treated OSA recurrence rate of Afib at 12 months was 42% Control group recurrence rate of Afib at 12 months was 53% P = Kanagala R, et al. Obstructive sleep apnea and the recurrence of atrial fibrillation. Circulation. 2003;107: OSA and Stroke The Sleep Heart Health Study 11 8 years follow-up Men with AHI > 19, adjusted hazard ratio of 2.86 (95% confidence interval, ) for ischemic stroke. P=0.016 Mild OSA - stroke risk by 6% (95% confidence interval, 2 10%) for each quarter percentile increase 11. Redline S, Yenokyan G, Gottlieb DJ, et al. Obstructive sleep apnea-hypopnea and incident stroke: the sleep heart health study. Am J Respir Crit Care Med. 2010;182:

6 Increase risks of death from stroke if you have OSA (adjusted hazard ratio, 1.76; 95% confidence interval, ; P =.03) 12 Independent of age, sex, BMI, smoking, hypertension, diabetes, afib, MMSE, and Barthel index of activities of daily living Using CPAP reduces mortality in setting of OSA and ischemic strokes Sahlin C, et al. Obstructive sleep apnea is a risk factor for death in patients with stroke: a 10-year followup. Arch Intern Med. 2008;168: Martinez-Garcia MA, et al. Continuous positive airway pressure treatment reduces mortality in patients with ischemic stroke and obstructive sleep apnea: a 5-year follow-up study. Am J Respir Crit Care Med. 2009;180:36-41 POLYSOMNOGRAPHY 4-Channel EEG EOG ECG Chin and Tibia EMG Airflow Monitor Pulse Oximeter Respiratory Effort Body Positioning Image Credit: Athens Center for Dental Sleep Medicine 6

7 Image Credit: Wikiwand Treatment Options for OSA WEIGHT LOSS EXERCISE AVOIDANCE OF ALCOHOL AVOIDANCE OF SEDATING MEDICATIONS AVOID SLEEPING SUPINE Treatment Options for OSA Mandibular Advancement Device CPAP Hypoglossal Nerve Stimulator Surgery Radiofrequency Ablation of Tongue Base Maxillomandibular Advancement Surgery Genioglossal Advancement Hyoid Suspension UPPP and tonsillectomy 7

8 Strollo P. et al. Upper-Airway Stimulation for Obstructive Sleep Apnea. N Engl J Med 2014; 370:

9 Benefits of CPAP CPAP use significantly reduced the occurrences of PAF (P < 0.001), PVC (P = 0.016), sinus bradycardia (P = 0.001), and sinus pause (P = 0.004) 14 Untreated severe OSA significantly increased the risk of fatal (odds ratio 2.87, 95%CI ) and non-fatal (3.17, ) cardiovascular events compared with healthy participants Abe H, et al. Efficacy of continuous positive airway pressure on arrhythmias in obstructive sleep apnea patients. Heart Vessels. 2010;25: Marin, JM. et al., Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005;365: IT S NOT JUST THE HYPOXIA In patients with cardiovascular disease or multiple cardiovascular risk factors, the treatment of obstructive sleep apnea with CPAP, but not nocturnal supplemental oxygen, resulted in a significant reduction in blood pressure Gottlieb, D. et al., CPAP versus Oxygen in Obstructive Sleep Apnea. N Engl J Med Jun 12; 370(24):

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