3/10/2014. Pearls to Remember. 1) Consequences of OSA related to both arousals and hypoxia. 2) Arousals provoke increased

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1 Cardiovascular disease and Sleep Disorders Timothy L. Grant, M.D.,F.A.A.S.M. Medical Director Baptist Sleep Center at Sunset Medical Director Baptist Sleep Education Series Medical Director Sleep Division Miami Research Associates Pearls to Remember 1) Consequences of OSA related to both arousals and hypoxia. 2) Arousals provoke increased sympathetic ti tone. 3) OSA may exist without snoring. 4) With difficult to control HTN and atrial fibrillation, look for occult OSA. Medical Disorders Associated With Sleep Disturbances Cardiovascular disease and OSA Cardiovascular Ds. Gastrointestinal Ds. Hypertension Endocrine Ds. Infectious Ds. Gastrointestinal Ds. Psychiatric Ds. Rheumatologic Ds. Neurological Ds. Menopause Chronic Pain ICU cases Intrinsic Respiratory Ds. Hematologic Ds. Hypertension Arrhythmias CHF Diabetes Pulmonary htn Obesity Metabolic Syndrome Syndrome Z Endothelial damage Vascular inflammation Oxidative stress Hypercoagulable state Obesity Non-dipping Sympathetic tone Typical Progression of Sleep Over the Course of the Night Dynamics of Sleep Architecture Awake REM Stage 1 Stage 2 Stage 3 Stage Time (h) Wake REM = rapid eye movement. Reprinted with permission from Erman MK. J Clin Psychiatry. 2001;62(suppl 10):9-17. First part of the night More slow wave sleep More parasympathetic tone More hemodynamically stable More NREM parasomnias (i.e. sleep walking) 1

2 Dynamics of Sleep Architecture Latter part of the night More REM sleep (sleep apnea is worse) More sympathetic tone More hemodynamically unstable More REM disorders (i.e. REM sleep behavior ds, nightmares) Common Sleep Disorders Each can be associated with a myriad of medical disorders Sleep Apnea (Obstructive and Central) Insomnia Periodic Limb Movements Restless Leg Syndrome REM Sleep Behavior Disorder Narcolepsy Hypersomnolence When is a PSG indicated? Stop-Bang Questionnaire Sleep Apnea Periodic Limb Movements (not RLS) Potentially y injurious nocturnal parasomnias Nocturnal Epilepsy with sleep complaint Precursor to f/u MSLT (daytime nap study) Not insomnia (unless suspect other sleep ds) Snoring Tiredness during daytime Observed Apnea High Blood Pressure BMI > 35 Age > 50 Neck Circumference > 40cm (15.75 inches) Male Gender Timothy L. Grant, MD, FAASM Ask the patient (or bed partner): Rationale for Treating Sleep Apnea Do you snore or stop breathing while asleep?? Do you have leg movement before or during sleep? Do you exhibit any bizarre or violent behavior in sleep? Are you excessively sleepy during the day? 1) Improved nocturnal sleep patterning 2) Awaken feeling more refreshed 3) Diminished Daytime Sleepiness 2

3 Rationale for Treating Sleep Apnea (cont.) Prevention of : Hypertension Cardiovascular Disease Cerebrovascular Disease Diabetes Depression Nocturia Sexual Dysfunction Morning Headaches Gastroesophageal Reflux Cognitive Impairment Cancer Probability of survival in patients with untreated OSA Cardiac Related Sequellae of OSA Coronary artery disease, MI Cardiac arrhythmias Atrial fibrillation, 1/3 with OSA, more successful cardioversion (80% vs 40%) CHF Hypertension 50%----50% Pulmonary hypertension Increased mortality Timothy L. Grant, MD, FAASM Sleep Apnea and Metabolic Syndrome Metabolic Syndrome X 1) Hypertension 2) Glucose Intolerance 3) Hyperlipidemia 4) Obesity Syndrome Z (Metabolic Syndrome + OSA) Timothy L. Grant, MD, FAASM Basic Types of Apneas Normal PSG, supine, in REM Obstructive Sleep Apnea (OSA) Mechanical obstruction with continued effort to breathe Central Sleep Apnea (CSA/CSR) Cheyne Stokes Respirations No mechanical obstruction, No effort to breathe Mixed Sleep Apnea Begins as a central and ends as an obstructive 3

4 Obstructive Sleep Apnea The effects of OSA lead to a pathological cascade that is responsible for cerebrovascular and other cardiovascular diseases. Timothy Grant, MD Durgan D J, and Bryan R M J Am Heart Assoc 2012;1:e Effects Of OSA Pathologic Changes with OSA Arousals from Sleep Hypoxia Hypercapnia p Sleep Deprivation Negative Intrathoracic Pressure Sympathetic Activation Oxidative Stress Inflammation (plasma cytokines,tnf,il-6) Endothelial Dysfunction Hypercoagulable State Metabolic Dysregulation OSA and Cardiovascular Disease 52 yo banker w/ prominent snoring and apneas observed by his wife, not him. HTN,Hyperlidpemia,BMI: OSA = Syndrome Z Increased sympathetic tone Chemoreflex stimulation Baroreflexes Mueller Maneuver Impaired venous return to the heart Changes in cardiac output PSG 2004 AHI of 112 O2 76% 2011 AHI 105 O2 83% ESS = 8 CPAP CPAP 11cm, AHI of 7, O2 96%. CPAP of 10cm, AHI of zero, O2 95% ESS = 2 4

5 CPAP IPAP = EPAP AUTO PAP (CPAP) IPAP=EPAP=Adjusting BIPAP IPAP higher, EPAP lower AUTO BIPAP (Bi-level) IPAP higher, EPAP lower, both adjusting VPAP/SERVOVENT EPAP stays the same, IPAP adjusts Coronary Artery Disease and OSA Increased risk of MI and cardiovascular ds. Increased arousals Recurrent hypoxia Decreased coronary blood flow Negative intrathoracic pressure Systemic inflammation Coagulopathy Endothelial dysfunction 5

6 Central Sleep Apnea Central Sleep Apnea Central Sleep Apnea (CSA/CSR) No mechanical obstruction No Effort to breath CSA associated with CHF Cerebrovascular disease Opiate usage High Altitude Timothy L. Grant, MD, FAASM Timothy Grant, MD Cheyne Stokes Respirations A form of Central Sleep Apnea 51 yo College Administrator with Complex/Central Sleep Apnea Labile HTN, CAD/stent, Cerebrovascular Ds AHI of 63 REM zero w/o PAP Min O2 76 with 55 min < 90%. Unresponsive to CPAP, and BIPAP with events central Event resolution, O2 normalization and REM rebound w/ SVPAP/Servovent Survival of heart failure patients with OSA Arrhythmias in OSA Kasai T, et al: Prognosis of patients with heart failure and obstructive sleep apnea treated with CPAP. Chest 133: , Bradycardia Sinus pause Heart block Ventricular ectopy and tachycardia Atrial fibrillation 6

7 Obstructive Sleep Apnea REM, O2 desaturations, 2 minutes Sinus Pause Supraventricular tachycardia in OSA Mechanism of arrhythmias in OSA Altered blood gases (hypoxemia, hyper & hypocapnia) Changes in autonomic tone Negative swings in intrathoracic pressure (which may distend the atria and ventricles) In the presence of coronary artery disease, the threshold for developing arrhythmias may be low. OSA and Atrial Fibrillation OSA and Atrial Fibrillation 3 million persons in US with AF Epidemiologic studies suggest OSA is a risk factor for new onset AF. OSA may confer worse prognosis for recovery after atrial fibrillation. 80% AF recurrence post cardioversion if untreated OSA. 50% of AF pts for cardioversion had OSA Increased AF post CABG if OSA Hypoxemia and obesity independent predictors of AF 7

8 OSA and Hypertension OSA 50% HTN Sleep Heart Study Linear relationship between SBP and DBP and OSA severity. Canadian population based study Each AH event per hour increased odds of HTN by 1% Each 10% reduction in nocturnal O2 sat increased likelihood of HTN by 13% OSA and Hypertension Becker HF: Systematic and pulmonary arterial hypertension in obstructive sleep apnea: Sleep Medicine Clinics: Sleep and Cardiovascular Disease. 2007, pp SHHS, OSA, CAD, Heart Failure Men with AHI >30 were 58% more likely to develop heart failure than those with AHI <5. OSA predicts CAD in men <70 Men with AHI > 30 were 68% more likely to develop CAD than those with AHI < 5. OSA predicted incident of heart failure in men but not Timothy women L. Grant, MD,FAASM CPAP Treatment of OSA Decreased Sympathetic arousals Normalizing dipping/nondipping Lowers BP Favorable effect on AF recurrence, esp after cardioversion Pearls to Remember Bibliography 1) Consequences of OSA related to both arousals and hypoxia 2) Increased sympathetic tone 3) OSA may exist without snoring (may also occur in nonobese, women, and young) 4) With difficult to control HTN and atrial fibrillation, look for occult OSA. Coughlin S.R., Mawdsley L., Mugarza J.A., et al: Cardiovascular and metabolic effects of CPAP in obese males with OSA. Eur Respir J 2007; 29: Gami A.S., Howard D.E., Olson E.J., et al: Day-night pattern of sudden death in obstructive sleep apnea. New Engl J Med 2005; 352: Kapa S., Javaheri S., Somers V.: Obstructive sleep apnea and arrhythmias. In: Javaheri S., Lee Chiong T., ed. Sleep Medicine Clinics: Sleep and Cardiovascular Disease, Philadelphia: WB Saunders; 2007: Marin J.M., Carrizo S.J., Vicente E., et al: Long-term cardiovascular outcomes in men with obstructive sleep apnea-hypopnea with or without treatment with continuous positive airway pressure: Observational studies. The Lancet 2005; 365: Young T., Finn L., Peppard P.E., et al: Sleep-disordered breathing and mortality: Eighteen-year follow-up of the Wisconsin Sleep Cohort. Sleep 2008; 31: Peppard P.E., Young T., Palta M., Skatrud J.: Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med 2000; 342(19): Timothy Grant, MD 8

9 Becker HF: Systematic and pulmonary arterial hypertension in obstructive sleep apnea: Sleep Medicine Clinics: Sleep and Cardiovascular Disease. 2007, pp Young T, Finn, Peppard, et al: Sleep-disordered breathing and mortality: Wisconsin Sleep Cohort. Sleep 31: ,2008. Lee Chong: Sleep Medine Clinics: i Sleep and CVD. 2007, pp Gottlieb, et al: Circulation,122: , Fialkow J. Cardiovascular Disease and Sleep Apnea. Baptist Sleep Education Series, 4/12/2013 Jaramillo S. Sleep and Neurologic disease. Baptist Sleep Education Series. Jan, Kasai T, et al: Prognosis of patients with heart failure and OSA treated with CPAP: Chest> 133: ,