Simple diagnostic tools for the Screening of Sleep Apnea in subjects with high risk of cardiovascular disease

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1 Cardiovascular diseases remain the number one cause of death worldwide Simple diagnostic tools for the Screening of Sleep Apnea in subjects with high risk of cardiovascular disease Shaoguang Huang MD Department of Respiratory Medicine, Ruijin Hospital, Shanghai Jiaotong University Medical school Cardiovascular diseases 30% Chronic respiratory diseases 7% Other chronic diseases 9% Diabetes melitus 2% Injuries 9% Cancer 13% burden of CV disease is particularly high Cammunicable, Matemal, and Perinatal Conditions, and Nutritional deficiencies 30% Projected global distribution of total deaths(58 million) by major cause, 2005 Strong et al, Lancet 2005 Cardiovascular disease #2 and #5 causes of premature death (years of life lost) Global Burden of Disease and Risk Factors I Colin D. Mathers, Alan D. Lopez, and Christopher J. L. Murray 2003 Global Burden of Disease and Risk Factors I Colin D. Mathers, Alan D. Lopez, and Christopher J. L. Murray 2003 Economic development in China has driven changes in diet and lifestyle, the proportion of adults with a high (>25) body mass index (BMI) rose from 9.1% to 19.7% from 1989 to Int J Obes (Lond) 2007; 31: Besides to control established risk factors, such as smoking, dyslipidaemia and high blood pressure ( hypertension ), Treatment of new risk factors, especially those related to the emerging epidemic of obesity, will also be important.

2 Severe OSA can cause Daytime Sleepiness Non-fatal cardiovascular events increased in patients with severe untreated OSA : 12 year clinic follow-up n = 1650 BUT also? OSA a new therapeutic target in prevention of cardiovascular disease Marin et al LANCET 2005 Potentially important contribution to CV disease since OSA is common Prevalence of OSAS (AHI 5 with EDS) USA, Spain, Australia -1990s 7% of adults (> 15 obstructive events/hr) see Young T et al, AJRCCM 2002 China Shanghai 23.7% severe snoring OSA a common but underdiagnosed condition > 5 Obstructions/hr + sleepy 3.6 % population HUANG Shaoguang et al 2003 Changchun > 5 Obstructions/hr + sleepy 4.8% population LI Ming-xian et al 2005 Prevalence of OSAS 5 Man 4 3 Women Wisconsin 1 Hongkong Shanghai Young T,et al. N Engl J Med. 1993;328: Ip MSM, et al. Chest 2001,119;62-69 Sleep Respiratory Disorder Study Group. Chin J Tuberc Respir Dis 2003; Aim Aim In contrast to patients presenting to sleep clinics, most people with moderate-severe OSA identified in surveys of general medical clinic populations or in the community are minimally symptomatic Simple diagnostic tools could facilitate the detection of OSA and the early application of treatments to reduce associated morbidity and risks of future disease. To document the prevalence of OSA in a high vascular risk recruited from primary Care

3 Study design A two-stage descriptive study was undertaken in a non-random sample of subjects with high CV risk identified from a local health register located in the Luwan district community of central Shanghai. Study design Recruitment of high CV risk subjects previous stroke or AMI two or more CV risk factors >55 yrs, hypertension, current smoking, diabetes, BMI >27 Study design Clinic visit Physical exam: weight, height, BP, ECG etc Questionnaires: Berlin (sleep apnea), Epworth Sleepiness Scale Study design Home testing Simultaneous PSG (Somte, Compumedics) and ApneaLink (ResMed; oximetry and nasal pressure) Successful study defined as >4 hrs valid recording for all signals Home Sleep Respiratory Test NORMAL ApneaLink (ResMed) ABNORMAL O2 dips Automated SaO2 and nasal pressure signal analyses

4 Apnea link report Simultaneous home screening device versus gold standard PSG ApneaLink Somte (Compumedics) 292 High CV risk patients screened in clinic 35 did not meet inclusion criteria refused or noncontactable 190 HOME TESTING: PSG and ApneaLink No OSA (AHI <15) (n=43) Mild OSA (AHI 15-29) (n=38) Moderate-severe OSA (AHI 30) (n=62) 143 Complete home sleep studies 51 failed home testing PSG alone (13), ApneaLink alone ( 26), Both (12) 4 repaeated successfully Moderate Severe OSA RESULTS Defined by polysomnography (PSG) as Apnea Hypopnea Index (AHI) > 30 events per hour 1999 Chicago criteria used for scoring respiratory events Moderate to Severe OSA: 62 of 143 (43%) The study showed that amongst community dwelling high CV risk subjects identified with moderate-severe OSA, approximately 75% were asymptomatic or minimally symptomatic (ESS < 10), 15% were moderately symptomatic (ESS 11-15) and only 10% were markedly symptomatic (ESS>15).

5 RESULTS RESULTS Berlin Questionnaire High risk Low risk Total AHI AHI < Berlin Questionnaire: high vs low risk Sensitivity 0.92, (91.9%; 95%CI %) Specificity 0.26, (25.9%; 95%CI %) +ve Predictive Value 0.49 ve Predictive Value 0.81 low risk Berlin result somewhat useful to rule out moderate- severe OSA RESULTS Using Bland-Altman plots, when compared to PSG AHI the ApneaLink devices were found to underscore consistently both desaturation events and nasal pressure AHI. The mean (95%CI) difference between PSG AHI and 4% desaturation event rate was ( ). The mean difference between PSG AHI and nasal pressure AHI was ( ). ROC & AUC Despite ApneaLink underscoring, the ROC curves for oximetry and nasal pressure as well as calculation of the area under the curve (AUC) were high for the diagnostic accuracy for moderate-severe OSA. Receiver operating characteristic (ROC) curves for oximetry and nasal pressure ODI threshold for diagnosis of OSA ROC curve Sensitivity (True +ve rate) sensitivity 83.9% specificity 84.0% ODI threshold of 12 events per hour Specificity (False +ve rate) The AUC for 4% desaturation-defined events was 0.933, with the closest point to the top left hand corner corresponding to an ODI threshold of 12 events per hour.

6 OXIMETRY n = 143 NASAL PRESSURE n = 143 AUC = 0.93 Optimal 4% Oximetry dip rate = 12/ hr Sensitivity 0.84 Specificity ve Predictive Value ve Predictive Value Likelihood ratio Likelihood ratio 0.19 AUC = 0.93 Optimal Nasal press event rate = 14/ hr Sensitivity 0.85 Specificity ve Predictive Value ve Predictive Value Likelihood ratio Likelihood ratio 0.17 Cut points (oxygen dip rates and airflow reduction events/ hr) for Moderate to Severe OSA in high CV risk population has been established in this Study ApneaLink failures 190 home studies Nasal pressure 36/190 (18.9%) Oximetry 11/190 (5.8%) Simultaneous home ApneaLink versus gold standard PSG by COMPUMEDICS Somte Conclusions Conclusions High prevalence of OSA (approx 45%) Various populations of patients suspected of having sleep apnea may not able to have sufficient sympatomatic. Berlin Q useful as initial screen rule outs about 25% of true negative cases, (also eliminates 8% of true positives) Nasal press and oximetry diagnostic accuracy But oximetry fewer study failures Oximetry preferred diagnostic method for detecting OSA in subjects with high risk of cardiovascular disease These data support the use of the simple diagnostic tools for sleep apnea in subjects with a high risk of cardiovascular disease

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