Baron Constantine Von Economo

Transcription

1 John Khoury

2 Baron Constantine Von Economo In 1916 first post mortem analysis on viral encephalitis lethargica patients. (Von Economo 1 Sleeping Sickness 1 ) Diagonal hatch marks: junction of midbrain and posterior hypothalamus causing hypersomnolence Horizontal hatch marks: basal forebrain and anterior hypothalamus lesions causing insomnia AQ : lesions of the lateral hypothalamus causing narcolepsy 1.Von Economo, C. Sleep as a problem of localization. J. Nerv. Ment. Dis. 71, (1930)

3 Socioeconomic Factors 40 million Americans suffer from chronic disorders of sleep and wakefulness. 95% of these remain unidentified and undiagnosed. The annual direct cost of sleep-related problems is $16 billion, with an additional $50-$100 billion in indirect costs (accidents, litigation, property destruction, hospitalization, and death).

4 Socioeconomic consequences More than 100,000 motor vehicle accidents annually are sleep-related. Disasters such as Chernobyl, Three Mile Island, Challenger, and Exxon Valdez were officially attributed to errors in judgment induced by sleepiness or fatigue.

5 The basics of sleep disordered breathing

6 Obstructive Sleep Apnea AHI = Apnea Hypopnea Index Apnea= Full airway closure with a 90% drop in airflow for at least 10 seconds Hypopnea= Partial airway closure (30% drop) associated with an oxygen desaturation of at least 3 or 4 % RERA = Respiratory Effort-Related Arousal = Partial airway closure associated with either an arousal

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8 Central Sleep apnea Caused by a reduction of respiratory effort and drive Absence of airflow occurs due to absent thoracoabdominal effort CNS or Neuromuscular

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10 Classifications Mild AHI = 5-15 events per hour Moderate AHI = events per hour Severe AHI = 30+ events per hour Abington Hospital Record 150 events per hour

11 Obstructive Sleep Apnea Syndrome Should have AHI >15 OR AHI between 5-15 AND have one of the following HTN MI/CAD Stroke/TIA A. fib Depression and other mood disorders Insomnia Hypersomnia

12 Demographics 1993: Prevalence of obstructive sleep apnea syndrome 1 2% of women 4% of men Today 2 when looking at AHI >5 9% of women 24% of men 1. Young T, Palta M Dempsey et al. The occurrence of sleep disordered breathing among middle aged adults 2. Lee W, Nagubadi S, Kryger MH, et al. Epidemiology of OSA: a population based perspective. Expert Rev Respir Med 2008; 2 (3):

13 Prevalence of OSA by disease Disease Prevalence BMI > % BMI > % Diabetes % Heart Failure 50 % Stroke and TIA 2 70% 1. Daniel Einhorn, MD, FACP, FACE, Deirdre A. Stewart, PhD, Milton K. Erman, MD, Nancy Gordon, MS, Athena Philis-Tsimikas, MD, and Eileen Casal, RN, MN. Prevalence of Sleep Apnea in a Population of Adults With Type 2 Diabetes Mellitus. Endocr Pract. 2007;13(4): Johnson KG, Johnson DC, Frequency of sleep apnea in stroke and TIA patients: A Meta-analysis. Journal Of Clinical Sleep Medicine. Volume 6. #

14 OSA in worsens non cerebral stroke HTN risk factors Atrial fibrillation and failed cardio version Insulin resistance Weight Increases, left ventricular hypertrophy, atrial size and increased transmural pressure OSA increases right to left PFO shunting

15 OSA in worsens cerebral stroke risk factors Increases oxidative stress and vascular inflammation causing endothelial dysfunction. Leads to reduced vasodilatation and enhanced vasoconstriction Apneas impair cerebral perfusion and autoregulation Cerebral blood flow velocity increases by 15% during an apnea and then decreases by 20% below baseline after the event ends 1 1. Bålfors EM, Franklin KA. Impairment of cerebral perfusion during obstructive sleep apneas. Am J Respir Crit Care Med Dec;150(6 Pt 1):

16 Sleep Heart Health study and primary stroke prevention

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18 What can we do after a patients stroke? Blood pressure Cholesterol Echo Fasting glucose/a1c Weight Smoking Status

19 Ask about sleep

20 Sleep apnea in secondary prevention Consecutive stroke patients Demographic similar in all final groups 7 year follow up Martínez-García MA, Campos-Rodríguez F, Soler- Cataluña JJ, Catalán-Serra P, Román-Sánchez P, Montserrat JM. Increased incidence of nonfatal cardiovascular events in stroke patients with sleep apnoea: effect of CPAP treatment. Eur Respir J Apr;39(4):906-12

21 AHI 0 9 events h 1 AHI events h 1 AHI 20 events h 1 noncompliant CPAP AHI 20 events h 1 with CPAP Subjects n Age yrs 69.5±11.8 # 73.5± ±9.4 # 71.3±11.9 Males 19 (61.3) 19 (48.7) 46 (67.6) 14 (50) BMI kg m ± ± ± ±3.8 Hypertension 20 (64.5) 24 (61.6) 48 (70.6) 17 (60.7) Previous stroke or TIA 10 (32.3) 10 (25.7) 23 (33.8) 7 (25) Previous IHD 7 (22.6) 6 (15.4) 17 (25) 4 (14.3) Atrial fibrillation 7 (22.6) 6 (15.4) 20 (29.4) 5 (17.9) Fibrinogen levels mg dl 1 335± ±88 328± ±84 Hypercholesterolaemia 14 (45.2) 19 (48.7) 36 (52.9) 15 (53.6) Oral anticoagulants 5 (16.2) 4 (10.3) 20 (29.4) 4 (14.3) Antiaggregants 29 (93.5) 37 (94.5) 64 (94.1) 27 (96.4) Antihypertensive drugs 14 (45.2) 18 (46.1) 31 (45.6) 11 (39.3) Current smoking 18 (58.1) 13 (33.3) 38 (55.9) 13 (46.4) Carotid stenosis 5 (16.1) 4 (10.3) 12 (17.6) 8 (28.6) Diabetes mellitus 9 (29) 18 (46.2) 28 (41.1) 8 (28.6) AHI events h 1 5.4±2.1 15± ± ±13.9 CT90% 6.1 (11) 7.2 (15.9) 10.6 (13.2) 10.8 (11.7) ESS 7.6± ±4.1 8± ±4.5 Barthel index 69.7± ± ± ±30 Glasgow coma score 14.5± ± ± ±1.2 LACI % POCI % TACI % PACI %

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23 Gross results AHI 0 9 events/hr AHI events/hr AHI 20 events/hr noncompliant CPAP AHI 20 events/hrwith CPAP Subjects CVEs 6 (19.4) 7 (17.9) 26 (38.2) 5 (17.9) Stroke 5 (16.1) 4 (10.6) 22 (32.4) 4 (14.3) Ischaemic stroke # 4 Haemorrhagic stroke Cardiac events Myocardial infarction Angor pectoris (3.2) 3 (7.7) 5 (7.4) 1 (3.6)

24 Unadjusted model Partly adjusted model # Fully adjusted model HR (95% CI) p-value HR (95% CI) p-value HR (95% CI) p-value Age 1.09 ( ) ( ) ( ) Barthel index 0.99 ( ) ( ) (0.98 1) Previous stroke or TIA 1.75 ( ) ( ) AHI <10 events h ( ) ( ) ( ) 0.91 AHÍ events h ( ) ( ) ( ) 0.31 AHI 20 events h 1 n ontolerant CPAP 2.26 ( ) ( ) ( ) AHI 20 events h 1 w ith CPAP 0.65 ( ) ( ) ( ) 0.71

25 The Number Needed to Treat NNT in the above study = 5 NNT for afib and stroke = 15 1 NNT for Aspirin = 29 2 NNT for Plavix = Andrew R. Woolfenden, MD, FRCPC, Gregory W. Albers, MD. Long-term stroke prevention in atrial fibrillation. Issue: BCMJ, Vol. 44, No. 3, April 2002, page(s) A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee. Lancet Nov 16;348(9038):

26 Sun-Wung Hsieh, Chiou-Lian Lai, Ching-Kuan Liu, Cheng-Fang Hsieh, Chung-Yao Hsu. Obstructive sleep apnea linked to wake-up strokes. J Neurol (2012) 259: Wake up strokes Case control study 71 stroke patients recruited after mild to moderate stroke 26 patients classified as wake up strokes All 71 pts had polysomonogram within two weeks of stroke No significant difference in demographics, stroke risk factors, heart rate variability Wake up stroke patients had higher AHI than non wake up stroke patients (23 events per hour vs 13) No other differences found between the two groups

27 STOP BANG Snore loudly Tired, sleepy or fatigue Observed Apnea (Blood) Pressure high (HTN) BMI > 35 Age > 50 Neck Circumference > 40 cm or 16 inches Gender = Man

28 Plot of predicted probabilities for AHI cut-offs of >5, >15, and >30 with the corresponding STOP-Bang score. 0,1,, 8 Chung F et al. Br. J. Anaesth. 2012;108: The Author [2012]. Published by Oxford University Press

29 Non Surgical Treatment options CPAP, BIPAP

30 Cloth masks for OSA

31 Dental Appliance

32 Provent therapy

33 Winx Device

34 Important Points OSA is an independent risk factor for stroke Dose responsive OSA treatment improves other stroke risk factors OSA is under recognized Sleep disordered breathing rates are the same for TIA and stroke Location of stroke, type and territory is not predictive of OSA OSA is treatable!

35 Michelangelo s Sistine Chapel

36 Questions?