Download Obstructive Sleep Apnea and Cardiovascular Disease

Obstructive Sleep Apnea and
Cardiovascular Disease
Chitra Lal, MD, D-ABSM, FCCP
Assistant Professor of Medicine
Medical University of South Carolina,
Charleston, SC
Faculty Disclosures
25th Annual Update in Psychiatry/MUSC, Charleston, SC
<Chitra Lal, MD, D-ABSM,FCCP>
• Personal financial interests in commercial entities that are
relevant to my presentation(s) or other faculty roles:
• No relevant commercial interests
• Non-commercial, non-governmental interests relevant to my
presentation(s) or other faculty roles:
• None
• Tobacco industry interests:
• None
Specific Questions
• Does OSAS play a role in the initiation of
cardiac and vascular disease?
• Does OSAS accelerate disease progression in
patients with established cardiovascular
disease?
• Does OSAS treatment result in clinical
improvement and reduced mortality from
cardiovascular disease?
Epidemiology
• Obstructive sleep apnea syndrome (OSAS) affects
approximately 15 million adult Americans (1)
• OSAS is seen in a large proportion of patients who
have hypertension, coronary artery disease, stroke
and atrial fibrillation (2)
• Prevalence of OSAS is 2% in women and 4% in men in
the 30-60 year age group (3)
(1) Caples SM et al, Obstructive sleep apnea Ann Intern Med 2005;142:187-197.
(2) Lattimore JD et al, Obstructive sleep apnea and cardiovascular disease J Am Coll Cardiol 2003;41:14291437.
(3) Young T et al, The occurrence of sleep-disordered breathing among middle-aged adults, NEJM1993 Apr
29;328(17):1230-5
Definitions
• OSAS is characterized by repetitive interruption of
ventilation during sleep caused by collapse of the
pharyngeal airway
• Apnea is ≥ 90% decrease in airflow for > 10
seconds
• Hypopnea (recommended AASM definition) :
decrease in airflow to ≥ 30% for 10 seconds with
≥ 4% desaturation
• Ongoing respiratory effort characterizes
obstructive events
Partial and complete airway obstruction resulting in hypopnea and apnea, respectively
Somers, V. K. et al. J Am Coll Cardiol 2008;52:686-717
Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply.
OSAS in Adults
• Mild OSAS : AHI ≥ 5/hour
• Moderate OSAS : AHI ≥ 15/hour
• Severe OSAS : AHI ≥ 30/hour
Clinical Features of OSAS
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Daytime Sleepiness
Nonrestorative sleep
Witnessed apneas
Insomnia
Narrow upper airway
Memory loss
Lack of concentration
Mood changes
Morning headaches
Polycythemia
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GERD
Vivid, strange dreams
Obesity
↑ neck circumference
Systemic hypertension
Hypercapnia
Cardiovascular disease
Stroke
Cardiac dysrhythmias
Pulmonary hypertension
STOP-BANG Questionnaire
• Snoring
• Tiredness
• Observed you stop
breathing
• Blood Pressure
• BMI > 35
• Age > 50
• Neck Circumference >
40 cm
• Gender Male
High Risk : Yes to ≥ 3 items → Refer for sleep testing
Cardiovascular
effects of OSAS
Systemic
hypertension
Pulmonary
hypertension
Arrhythmias
Coronary
artery
disease
Heart
Failure
Stroke
OSAS and
Systemic
Hypertension
↑
Prevalence
&
incidence
Doseresponse
effect
Treatment
effect
Epidemiological Data
• Cross-sectional analysis of 6132 participants of
Sleep Heart Health Study (4)
• Age ≥ 40 years, 52.8% females
(4) Nieto FJ et al, JAMA, 2000 Apr 12;283(14):1829-36
Adjusted Odds Ratio (OR) and 95% Confidence Intervals (CIs) of Hypertension by SleepDisordered Breathing Measures, Sleep Heart Health Study, 1995-1998*.
Nieto, F. J. et al. JAMA 2000;283:1829-1836
Copyright restrictions may apply.
Prevalence of Snoring, Mean Levels of Sleep-Disordered Breathing Indicators, and Mean
Blood Pressures, by Apnea-Hypopnea Index (AHI) Category, Sleep Heart Health Study, 19951998*.
Copyright restrictions may apply.
Nieto, F. J. et al. JAMA 2000;283:1829-1836
OSAS and Systemic Hypertension
• Prospective study of 709 participants in the
Wisconsin Sleep Cohort (5)
• Data analysed at baseline, after 4 years and 8
years of follow-up
(5) Peppard PE et al, NEJM, 2000 May 11;342(19):1378-84
Peppard PE et al, NEJM, 2000 May 11;342(19):1378-84
OSAS and Systemic Hypertension
• Double-blind, placebo-controlled trial of 86
OSAS patients randomized to receive
therapeutic cpap for 3 months followed by
sham-cpap for 3 months or vice-versa (6)
(6) Sharma SK et al, NEJM, 2011 Dec 15;365(24):2277-86
OSAS and Resistant Hypertension
• Blood pressure ≥ 140/90 mm Hg using at least
3 anti-hypertensive drugs (at least 1 diuretic)
• Case-control study of 63 case patients with
resistant hypertension and 63 control patients
with controlled hypertension on medications (7)
(7) Goncalves SC et al, Chest, 2007 Dec;132(6):1858-62
Goncalves SC et al, Chest, 2007 Dec;132(6):1858-62
Goncalves SC et al, Chest, 2007 Dec;132(6):1858-62
Comparison of CPAP and valsartan in hypertensive patients with sleep apnea
Pepin JL et al, AJRCCM,
2010 Oct 1;182(7):954-60
Key Points
• Systemic hypertension is more common in
patients with OSAS than in those without
OSAS
• Severity of OSAS corresponds to likelihood of
systemic hypertension
• Decrease in blood pressure with cpap is small
and less then with medications but significant
• Consider OSAS in patients with resistant
hypertension
OSAS and Pulmonary Hypertension
• Pulmonary hypertension (PH) in OSAS is typically mild
(mean PAP ≤ 26 mm Hg) (8)
• Cor pulmonale is more likely to occur in patients with
diurnal hypoxemia then in those with just nocturnal
hypoxemia (9)
• PH can occur in OSAS in the absence of lung disease (8)
• Presence of PH decreases overall survival (10)
(8) Sajkov D et al, AJRCCM, 1994 Feb;149(2 Pt 1):416-22
(9) Bradley TD et al, Am Rev Repir Dis, 1985 Jun;131(6):835-9
(10) Minai OA et al, Am J Cardiol, 2009 Nov 1;104(9):1300-6
Kaplan-Meier survival curves
in 83 OSAS patients,
Minai OA et al, Am J Cardiol,
2009 Nov 1;104(9):1300-6
Arias MA et al, Eur Heart J, 2006 May;27(9):1106-13. Epub 2006 Feb 23
Key Points
• OSAS causes mild PH
• Presence of PH should prompt the clinician to
screen for evidence of OSAS
OSAS and Coronary Artery Disease
• Severe OSAS is associated with increased
morbidity and mortality due to coronary artery
disease (CAD)
• Prospective cohort study of 1651 men who were
followed for a mean of 10 years (11)
(11) Marin JM et al, Lancet, 2005 Mar 19-25;365(9464):1046-53
Marin JM et al, Lancet, 2005 Mar 19-25;365(9464):1046-53
Marin JM et al, Lancet,
2005 Mar 19-25;365(9464):1046-53
OSAS and Coronary Artery Disease
• OSAS can exacerbate pre-existing CAD
• Prospective cohort study of 89 consecutive patients
who underwent percutaneous coronary intervention
for acute CAD (12)
• Incidence of major cardiac adverse events (MACE) was
higher in patients with OSAS than those without OSAS
(adjusted HR 11.6, 95% CI 2.2-62.2)
(12) Tsurumi Y et al, Am J. Cardiol., 2007 Jan 1;99(1):26-30. Epub 2006 Nov 2
Tsurumi Y et al, Am J. Cardiol., 2007 Jan 1;99(1):26-30. Epub 2006 Nov 2
OSAS and Coronary Artery Disease
• Can CAD worsen OSAS?
• Prospective cohort study of 2721 patients
(mean age 62 years) without known
cardiovascular disease followed for 5 years (13)
• Polysomnogram perfomed at baseline and
after 5 years
(13) Chami HA et al, Circulation, 2011 Mar 29;123(12):1280-6. Epub 2011 Mar 14
Chami HA et al, Circulation, 2011 Mar 29;123(12):1280-6. Epub 2011 Mar 14
Key Points
• OSAS increases morbidity and mortality due to
CAD (especially severe OSAS)
• CAD can also worsen OSAS
• CPAP may reduce adverse events related to
CAD
OSAS and
Arrhythmias
Bradycardia,
Asystole
Tachyarrhythmias
Atrial
Fibrillation
Ventricular
tachycardia
OSAS and Cardiac Arrhythmias
• Observational study of 228 patients with RDI ≥
30/hour compared to 338 controls with RDI ≤
5/hour (14)
• OSAS patients had a higher prevalence of
nocturnal arrhythmias
(14) Mehra R et al, AJRCCM, 2006 Apr 15;173(8):910-6. Epub 2006 Jan 19
Mehra R et al, AJRCCM, 2006 Apr 15;173(8):910-6. Epub 2006 Jan 19
OSAS and Cardiac Arrhythmias
• Bradycardia and asytole are the most
prominent and significant rhythm
disturbances
• OSAS can cause bradyarrhythmias during
waking hours (15)
(15) Garrigue S et al, Circulation, 2007 Apr 3;115(13):1703-9. Epub 2007 Mar 12
OSAS
↓SO2
↑pCO2
↓pH
↑Vagal
tone
Bradyarrhythmias
Mueller’s
maneuver
OSAS and Atrial Fibrillation
• Prevalence of atrial fibrillation (AF) in OSAS patients
is low but higher than in the general population (14)
• Prevalence of OSAS in AF patients is very high (32%82%) (16, 17)
• OSAS can be associated with recurrent atrial
fibrillation (18)
(14) Mehra R et al, AJRCCM, 2006 Apr 15;173(8):910-6. Epub 2006 Jan 19
(16) Porthan KM et al, Chest, 2004 Mar;125(3):879-85
(17) Gami AS et al, Circulation, 2004 Jul 27;110(4):364-7. Epub 2004 Jul 12
(18) Kanagala R et al, Circulation, 2003 May 27;107(20):2589-94. Epub 2003 May 12
OSAS and Cardiac Arrhythmias
• CPAP decreases nocturnal ventricular asystole and bradycardia in
OSAS patients (19)
• Impact of CPAP on other arrhythmias is unknown
• Impact of other therapies for OSAS on cardiac arrhythmias
is unknown
• Long term data on impact of therapy on mortality is lacking
(19) Simantirakis EN et al, Eur Heart J, 2004 Jun;25(12):1070-6
Key Points
• Patients with nocturnal or daytime
arrhythmias and those with pacemakers
should undergo evaluation for OSAS
OSAS and Heart Failure
• Prospective cohort study of 1927 men and
2495 women without baseline heart failure
followed for a median of 8.7 years (20)
• Baseline polysomnogram performed
• Men with severe OSAS had greatest risk of
developing heart failure
• No increase in heart failure in women
(20) Gottlieb DJ et al, Circulation, 2010 Jul 27;122(4):352-60. Epub 2010 Jul 12
Gottlieb DJ et al, Circulation, 2010 Jul 27;122(4):352-60. Epub 2010 Jul 12
OSAS and Heart Failure
• Observational study of 700 patients with heart
failure revealed a 36% prevalence of OSAS (21)
(21) Oldenburg O et al, Eur J Heart Fail, 2007, 9 (3): 251-257.
OSAS
↑LV
afterload
Cor
pulmonale
CAD
Heart Failure
Progression
↑Sympathetic
tone
Heart
Failure
Fluid
retention
Airway
congestion
↑ AHI
Kaneko Y et al, NEJM, 2003 Mar 27;348(13):1233-41
Kaneko Y et al, NEJM, 2003 Mar 27;348(13):1233-41
Key Points
• Severe OSAS can cause development of heart
failure in men
• OSAS can cause progression of heart failure
• Heart failure may potentially increase the AHI
• CPAP can improve left ventricular ejection
fraction in OSAS patients
OSAS and Stroke
• Prospective cohort study of 5422 individuals
without history of stroke (22)
• Median follow up for 8.7 years
(22) Redline S. et al, AJRCCM, 2010 Jul 15;182(2):269-77
Redline S. et al, AJRCCM, 2010 Jul 15;182(2):269-77
Redline S. et al, AJRCCM, 2010 Jul 15;182(2):269-77
OSAS
↑ BP
Inflammation
Heart
Disease
Endothelial
dysfunction
Stroke
Diabetes
mellitus
Johnson KG et al, J Clin Sleep Med, 2010;6:131
Parra O et al, AJRCCM, 2000;161:375
Key Points
• OSAS increases stroke risk
• High prevalence of OSAS after stroke
• OSAS can lead to early neurologic deterioration after
stroke (23)
• OSAS improves as stroke improves over time (24)
• CPAP treatment for OSAS may improve long term
cardiovascular and neurologic outcomes after stroke (25)
(23) Iranzo A et al, Neurology, 2002 Mar 26;58(6):911-6
(24) Parra O et al, AJRCCM, 2000;161:375
(25) Parra O et al, Eur Respir J. 37; 1128-1136
Conclusion
• OSAS is associated with significant morbidity
and mortality due to cardiovascular disease
• Early recognition and treatment of OSAS is the
key to prevention of adverse cardiovascular
consequences