Obstructive Sleep Apnea and its Effects on Cardiovascular System

Transcription

1 The image part with relationship ID rid2 was not fond in the file. Obstrctive Sleep Apnea and its Effects on Cardiovasclar System TODD MONROE, MD, FACC

2 The image part with relationship ID rid19 was not fond in the file. Disclosres None financial I am a private practice interventional cardiologist I have OSA I am compliant with CPAP I have had bariatric srgery

3 The image part with relationship ID rid19 was not fond in the file. Obstrctive Sleep Apnea is: Common Potentially dangeros Easily recognizable Treatable

4 The image part with relationship ID rid19 was not fond in the file. Cardiovasclar Disease is: Common Potentially dangeros Easily recognized Treatable

5 The image part with relationship ID rid19 was not fond in the file. Overview of OSA & Cardiovasclar System Pathophysiology Obstrctive Sleep Apnea and: HTN Myocardial ischemia and infarction CHF Cardiac dysrhythmias CVA Effects of OSA treatment on CV disease Smmary

6 The image part with relationship ID rid19 was not fond in the file. Pathophysiology of OSA Awake: Small airway and neromsclar compensation With sleep onset there is: Loss of neromsclar compensation > decreased pharyngeal mscle activity Airway collapse > apnea > hypoxia/hypercapnia Increased ventilatory effort > sleep arosal > phayngeal mscle activity restored Airway opens > hyperventilate correcting hypoxemia/hpercapnia Sleep > REPEAT

7 The image part with relationship ID rid19 was not fond in the file. Clinical Conseqences of OSA OSA > fragmented sleep > Excessive daytime somnolence > Increased M & M OSA > Cyclic hypoxemia/hypercapnia > CV disease/metabollic complications > Increased M & M

8 The image part with relationship ID rid19 was not fond in the file. Pathophysiology of Sleep on CV System Effects of Normal Sleep on CV System Decreased metabolic rate Decreased sympathetic nervos system activity Decreased blood pressre Increased vagal tone Decreased heart rate Effects of Sleep Disordered Breathing on CV System Increased sympathetic nervos activity Increased blood pressre Decrease parasympathetic nervos system activity Increased heart rate Bradley & Flores, The Lancet, :82-93

9 The image part with relationship ID rid19 was not fond in the file. Impact of OSA on the CV System Hypoxia cases noctrnal ischemia throgh: Increased metabollic demands on the heart Decreased cardiac contractility Increased PA pressres Sleep arosal cases repetitive cardiac strain: Increase in sympathetic nervos activity Cyclic srges in HR & BP Naghton, Circ. 1995

10 The image part with relationship ID rid19 was not fond in the file. Effects of Apnea Indced Hypoxia and Hypercapnia Apnea cases Cyclic changes in sympathetic mediated peripheral vasoconstriction leading to increased systemic BP Decreased vagal tone leading to increased HR Increased negative intrathoracic pressre Increased RV preload Increased afterload/lv transmral pressre(lvh/ischemia) Hypoxia cases Plmonary vasoconstriction Increased RV afterload and RV distention Impaired LV diastolic filling and decreased LV stroke volme Bradley and Flores, Lancet, :82-93

11 The image part with relationship ID rid19 was not fond in the file. Effects of OSA on Vasclatre Hypoxia cases increased risk of thrombosis Formation of O2 free radicals Impaired vasclar endothelial fnction Activation of inflammatory pathways Hypercoaglability de to platelet activation Vasclar smooth mscle proliferation Increased morning fibrinogen levels Decreased plaminogen activator inhibitor type I activity Lancet, :82-93

12 The image part with relationship ID rid19 was not fond in the file. Obstrctive Sleep Apnea and Hypertension Known case of HTN Patients with OSA are more likely to develop HTN Joint National Comm. on Detection and Management of HTN as an important identifiable case of HTN Possible mechanisms inclde: hypoxemia, chemoreceptor stimlation, sympathetic activation, and activation of renin/angiotensin system Animal models Chobanian, JAMA. 2003; Lesske, J Hypertension Dogs exposed to OSA developed HTN dring both sleep and wake and reversed with removal of OSA Rats exposed to intermitent hypoxia developed HTN and was prevented by sympathectomy or peripheral chemoreceptor denervation Lancet, : 82-93

13 The image part with relationship ID rid19 was not fond in the file. OSA & HTN cont d Very common in medication resistant HTN 3 Observational stdies showed >70% of patients with difficlt to treat HTN or resistant HTN have OSA vs < 40% of those with controlled HTN Logan, Er Respir J, 2003.;Goncalves, Chest, 2007.: Logan, J Hyperten, IF A PATIENT IS ON 3 OR MORE ANTI-HTN MEDS THINK UNTREATED OSA

14 The image part with relationship ID rid19 was not fond in the file. OSA and Risk of Myocardial ischemia and AMI In patients with known CAD, OSA was associated with: Higher mortality More major cardiac events Higher rates of restenosis following PTCA Prospective stdy(2005) showed more fatal and non-fatal AMI in those with severe ntreated OSA vs control. No difference in rates of those with OSA treated with CPAP vs controls. Case/control stdy showed a graded increase in odds of AMI with increaseing severity of sleep apnea. Somers, et al, Circ, : Marin, et al, Lancet, : Ymino, et al, Am J Cardiol, : 26-30

15 The image part with relationship ID rid19 was not fond in the file. OSA and Relation to CHF CHF patients with OSA have worse prognosis than CHF patients withot sleep apnea Prospective OSA/CHF stdy 164 patients with LVEF<45% OSA with AHI > 15 3 year follow-p Ancili-Israel, Chest Patients with OSA had increase cardiac mortality than those withot; 8.7 vs 4.2 deaths /100 patient years Wang, JACC. 2007

16 The image part with relationship ID rid19 was not fond in the file. OSA & Cardiac Dysrhythmias Increased freqency of arrhythmias in patients OSA Increase in arrhythmias with increase in nmber of apneic events Increase in arrhythmias with severity of O2 desatrations Occr in p to 50% of patients with OSA Most common arrhythmias: NSVT, Freqent isolated PVC s and PAC s, sins arrest, and PAFIB Somers et al, Circ, :

17 The image part with relationship ID rid19 was not fond in the file. OSA and PAFIB Increased likelihood of PAFIB in patients with OSA vs controls 50% recrrence rate of PAFIB following cardioversion in patients with OSA vs general cardiology poplation withot. Mechanisms inclde: Left atrial enlargement Hypoxemia Sympathetic activation Ischemia Systemic inflammation Somers et al, Circ, ; Otto et al, Am J Cardiol, 2007

18 The image part with relationship ID rid19 was not fond in the file. Effects of OSA on the Cerebrovasclar System Decrease in cerebral blood flow de to hypercapnia In OSA patients vs controls: Increase carotid intima-media thickness Decrease arterial compliance Increase incidence of silent cerebral infarcts Lancet, 2009.

19 The image part with relationship ID rid19 was not fond in the file. Obstrctive Sleep Apnea and CVA Mod/severe OSA(AHI>20) vs No OSA had 4.33 greater odds of stroke. Sleep Heart Health Stdy showed in patients with OSA: 1.6 times higher CVA risk in highest vs lowest AHI qartiles. In another stdy of OSA and CVA Pts > 70 yrs of age Severe OSA(AHI > 30) vs OSA(AHI < 30) 2.5 times increased risk of CVA at 5 yr follow p Lancet, 2009; Artz et al, Am J Respir Crit Care Med, : Mnoz et al, Stroke, :

20 The image part with relationship ID rid19 was not fond in the file. OSA and CVA cont d Several stdies in OSA patients compared to those withot, who are post CVA have: Increased risk of recrrent CVA and death. Decreased motivation and cognitive capacity Dring rehab, had worse fnctional impairment and spent longer time in hospital and rehab.

21 The image part with relationship ID rid19 was not fond in the file. Treatment of OSA with CPAP Physiologic effects of CPAP Reversal of noctrnal hypoxemia and hypercapnia Resoltion of apnea-indced arosals Reversal of intrathoracic pressre abnormalities and cardiac distention Decreased inflammatory marker levels Decrease in morning fibrinogen levels Lancet, 2009.

22 The image part with relationship ID rid19 was not fond in the file. Effect of CPAP Therapy on HTN Acte and significant decrease in BP and sympathetic activity Mltiple stdies showed significant drop in BP with therapetic vs sham(control) CPAP Better BP response to CPAP in patients with: More severe OSA Difficlt to control HTN Better CPAP compliance In patients intolerant of CPAP, oral appliance therapy may also lower BP Somers, et al, J Clin Invest, : Pepperell et al, Lancet, : Dimsdale et al, HTN, : Becker et al, Circ, : 68-73

23 The image part with relationship ID rid19 was not fond in the file. Effect of CPAP Therapy on CHF Redction of noctrnal BP and HR Mltiple reports of : Improved LVEF Decreased sympathetic vasoconstrictor activity Decreased noctrnal rinary norepinephrine levels Tkacova et al, Circ, : Malone et al, Lancet, : Somers et al, Circ, 2008.

24 The image part with relationship ID rid19 was not fond in the file. Effects of CPAP Therapy on Myocardial Ischemia and AMI Treated OSA pts had fewer cardiac events than ntreated pts. Treated OSA pts had decreased cardiac mortality than ntreated pts. Noctrnal angina and ST depressions are improved with CPAP Opposing reslts NEJM, to come Somers, Circ, Milleron et al, Er Heart J, : Doherty et al, Chest, :

25 The image part with relationship ID rid19 was not fond in the file. Effects of CPAP on Cardiac Dysrhythmias 82% risk of AFIB recrrence after cardioversion in ntreated OSA pts vs abot 40% of pts that were treated Japanese stdy showing increasing prevalence of PAFIB in pts with increased severity if OSA had signficant redction in PAFIB with CPAP treatment. Randomized, controlled trial: 58% redction in freqency of PVC s after one month of CPAP in OSA pts and systolic dysfnction Redction in rinary norepi concentrations Abe, Heart Vessel,2010: 25: 63-9 Somers et al, Circ, 2008 Ryan et al, Thorax, : Kanagala et al, Circ, : Gami, Circ, : 364-7

26 The image part with relationship ID rid19 was not fond in the file. Effects of CPAP on CVA CPAP compliance and tolerance are poor in CVA pts and beneficial effects have not been confirmed Pts shold still be treated Somers, Circ, 2008.

27 The image part with relationship ID rid19 was not fond in the file. CPAP for Prevention of Cardiovasclar Events in OSA Secondary prevention trial in patients with docmented CV disease & OSA SAVE grop(sleep Apnea Cardiovasclar Event) McEvoy et al, NEJM, : Large mlti-contry stdy with 15,325 pts assessed for eligibility 2,717 pts nderwent randomization to sal care(1256) vs CPAP pls sal care(1284) Primary endpoints with mean follow-p 3.7 yrs were death from CV case, AMI, CVA, or hospitalization for nstable angina, CHF or TIA Secondary endpoints inclded other CV otcomes(admit for CHF or TIA, and PAFiB), health related qality of life, snoring symptoms, daytime sleepiness and mood.

28 The image part with relationship ID rid19 was not fond in the file. CPAP for Prevention of CV Events in OSA Reslts: No significant redction in CV events was noted for primary or secondary CV otcomes endpoints in the CPAP treated grop Improvement in qality of life measres were significant in the CPAP treated grop(decreased daytime sleepiness, decreased anxiety and depression and fewer work days missed) Stdy limitations: Some of the participating contries did not have well established OSA criteria for diagnosis and treatment Mean adherence to CPAP among participants was mean of 3.3 hrs/night

29 The image part with relationship ID rid19 was not fond in the file. Smmary of OSA and CV Disease Common Dangeros Easily Recognized Treatable COMPLEXLY INTERTWINED WITH CONFLICTING DATA

30 The image part with relationship ID rid19 was not fond in the file. Smmary of OSA and CV Disease In my CV disease patients, HTN patients, Diabetic patients: Thorogh history and physical Psh for formal testing Encorage CPAP compliance in patients with OSA Reasons to se CPAP Make it easier to treat blood pressre/maybe se less medicine Make it easier to treat Diabetes/maybe se less medicine Controlling these things may make yo less likely to have a cardiovasclar event Make PAFIB easier to control MAKE YOU FEEL BETTER/MAKE YOUR SPOUSE HAPPIER

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