Sleep Apnea

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Sleep Apnea CHD

• Ibrahim Elias Fahdi, MD, FACC
• Assistant Professor of Internal Medicine
• Division, Cardiovascular Medicine

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Disclaimer

• I am not a respiratory therapist
• I am not a pulmonologist
• I am just a cardiologist ?

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Parish et al. Mayo Clin Proc. 2004 79(8) 1036-46
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Our only hope is if we all write a letter to
Santa
The Wall Street Journal
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Objectives

• To shed some light on the relationship between
  sleep apnea
• Hypertension
• Acute Coronary Syndrome
• Congestive Heart Failure
• Arrhythmia
• Stroke

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Sleep Physiology

• During NREM sleep, the reduced metabolic rate
  increases parasympathetic nervous system tone,
  decreases sympathetic nervous system activity,
  and activates the baroreflex sensitivity,
  resulting in decreasing heart rate, blood
  pressure, stroke volume, cardiac out-put, and
  systemic vascular resistance

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Epidemiology

• Apnea is defined as cessation of air flow for a
  minimum of 10 seconds.
• Hypopnea is defined as 30-50 reduction of air
  flow for a minimum of 10 seconds with or without
  2-4 O2 desaturation.

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Epidemiology

• Apnea-hypopnea index (AHI)
• Normal
• Mild 5-15 per hour
• Moderate 15-30 per hour
• Severe 30 per hour

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Epidemiology

• 4 of men and 2 of women aged 30-60 years have
  OSA.
• Affect all age groups including children.
• MF 21, children and elderly MF.
• More prevalent in industrialized world, parallel
  the obesity endemic.
• Mortality 40 with severe OSA died within 8
  years of follow up

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Risk Factors

• Obesity.
• Age of more than 65 years.
• Male gender.
• Positive family history.
• Race ( more in AA, Mexican A, Asians)
• Smoking.
• Alcohol and sedative medications.
• Allergies and nasal congestion.
• Supine position.

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Sleep-Related Breathing Disorders

• Snoring (primary snoring)
• Obstructive sleep apnea (OSA)
• Repetitive apnea/hypopnea
• Symptoms
• Central sleep apnea (CSA)
• Upper airway resistance syndrome

McNicholas et al. Eur Respir J 2002 201594-609
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Obstructive Sleep Apnea

• OSA is characterized by episodes of complete or
  partial pharyngeal obstruction during sleep.
• Key feature of OSA is that patients will make
  persistent efforts to breathe against occluded
  upper airways

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Prevalence
Lattimore et al. JACC. 2003 41 1429-37
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Central Sleep Apnea

• Repeated episodes of apnea during sleep resulting
  from loss of ventilatory effort.
• No upper airway obstruction.
• Represent 10 of patients with sleep apnea.
• Not a single entity cheyne-Stokes respiration,
  periodic breathing at altitude, idiopathic
  central apnea.
• CHF.
• Stroke.

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Day-time Symptoms

• Sleepiness.
• Fatigue.confused with sleepiness.
• Morning headache.
• 50
• dull and generalized.
• last 1-2 hrs after awakening.
• Poor concentration.
• Decreased libido in up to 30 of patients.
• Decreased attention.
• Depression.
• Personality change. aggressiveness, irritability,
  anxiety

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Night-time Symptoms

• Nocturnal symptoms
• Snoring
• Witnessed apnea.
• Chocking.
• Dyspnea.decreased intrathoracic pressure,
  increased venous return, increased capillary
  wedge pressure. Resolve quickly upon awakening as
  opposed to CHF.
• Restlessness.
• 50
• increased effort of breathing.
• can be violent.

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Snoring

• - Not all snorers have OSA.(primary snoring)
• - Virtually occur in all patients.
• - Absence doesn't exclude OSA or UARS.
• - Can be soft or extremely loud.
• - Alternate with episodes of silence lasting
  20-30 S.
• - Usually precede daytime sleepiness.
• - Intensity increase with weight gain and
  bedtime alcohol use.
• - Cause major marital discord.

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Parish et al. Mayo Clin Proc. 2004 79(8) 1036-46
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Normal physiology
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OSA Hypertension

• HTN is a clinical marker of OSA.
• 40 of OSA patients have HTN.
• 30 of HTN patients have OSA.
• Each extra apneic episode per hour increase the
  odd ratio of HTN by 1
• Treatment of OSA reduces daytime blood pressure.

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CPAP BP
Lattimore et al. JACC. 2003 41 1429-37
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Ischemic heart disease

• Evidence favoring an association between OSA and
  ischemic heart disease.
• Nocturnal hypoxia and autonomic nervous system
  activity during apnea may well predispose
  susceptible patient to ischemia, nocturnal angina.

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Gami et al. NEJM 2005. 352 12
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Gami et al. NEJM 2005. 352 12
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Gami et al. NEJM 2005. 352 12
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Sleep disturbance CHF

• Patients with HF are 6 to 9 times more likely to
  experience sudden cardiac death than healthy
  population
• Approximately 20 of patients die within a year
  after HF diagnosis
• Cost of HF care in US for 2007 33.2 billion

Chen et al. J of cardiovascular Nursing. 2007
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Arrhythmia

• Sinus arrhythmias.
• Sinus bradycardia with sinus arrest.
• Atrial tachycardia with A-fib/flutter
• PVCs.
• Sudden death during sleep.

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Stroke

• Odds ratio for stroke in snoring patient is 3.2,
  for OSA with obesity is 8.
• Stroke can lead to OSA by interfering with
  innervations to the upper airway muscles.

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Clinical Evaluation
Lattimore et al. JACC. 2003 41 1429-37
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Diagnosis

• History
• Overnight pulse oximetry
• Polysomnography

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Treatment of Sleep Apnea

• Modification of behavioral factors.
• weight loss
• avoid alcohol and sedatives.
• positional treatment.
• Nasal CPAP.
• non-invasive.
• very effective.
• patient adherence and acceptance.

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Is it familiar
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US the World!
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Happy Friend
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Effects of CPAP

• Effects on hemodynamics
• Reduced preload and afterload.
• Increase cardiac output.
• Increased LVEF.
• Alleviation of symptoms in CHF and pulmonary
  edema.
• Alleviation of nocturnal and daytime
  hypertension.
• Effects on respiratory system
• Abolition of sleep apnea.
• Improvement in nocturnal oxygenation.
• Alleviation of dyspnea and symptoms of sleep
  apnea.
• Effects on neurohormonal activity
• Reduced sympathetic nervous activity.
• Increased barorelex sensitivity.
• Increased heart rate variability.
• Reduced ANP concentration.

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Adherence
I think the dosage needs adjusting. Im not
nearlyas happy as the people in the ads.
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Summary

• Death is inevitable!
• We have a say of how soon we want it and how
  healthy, independent, we want to be, appreciating
  the quality of life that we are living
• Treatment does not start with medication, it
  starts with PREVENTION
• You could help by education monitoring

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Division of Cardiovascular Medicine4301 West
Markham, Slot 532Little Rock, AR
72205-7199(501) 686-8000
http//www.uams.edu/cardiology/