Timothy L. Grant, MD,FAASMcme.baptisthealth.net/cvdprevention/documents/2015... · treatment on overall cardiovascular health. Timothy L. Grant, MD,FAASM Sleep Disordered Breathing

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Sleep Apnea: Advances in Diagnosis and Treatment to Lower CVD Risk

• 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

2015

Speaker Disclosures

•� I have no relevant commercial relationships

to disclose.� All conflicts of interest of any individuals who

control the content of this CME activity, including faculty and members of the Continuing Medical Education Committee and the Continuing Medical Education Department, have been identified and resolved.

Timothy L. Grant, MD,FAASM

ObjectivesObjectives

� Discuss the prevalence of sleep disordered breathing in cardiac patients and implement strategies to optimize treatment of sleep disorders in the cardiac patient.

� Recognize the various types of sleep disorders seen in the cardiac patient.

� Explain the benefits of sleep apnea treatment on overall cardiovascular health.


Sleep Disordered BreathingPearls to Remember

1) Consequences of OSA related to both arousals and hypoxia.

2) Arousals provoke sympathetic tone.3) OSA may exist without snoring or

obesity.4) With difficult to control HTN and atrial

fibrillation, look for occult OSA.

5) survival w/ SDB Rx interventionTimothy L. Grant, MD,FAASM

Medical Disorders Associated With Sleep Disturbances

� 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.


Common Sleep DisordersEach can be associated with a myriad of

medical disorders including CVD.

•� Sleep Apnea (Obstructive and Central)� Insomnia� Periodic Limb Movements� Restless Leg Syndrome� REM Sleep Behavior Disorder� Narcolepsy� Hypersomnolence


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Cardiovascular disease and OSA

Disease:• Hypertension• Arrhythmias• CHF• Diabetes• Pulmonary htn• Obesity• Metabolic Syndrome• Syndrome Z

Mechanism: • Endothelial damage• Vascular inflammation• Oxidative stress• Hypercoagulable state• Obesity• Non-dipping• Sympathetic tone


Typical Progression of Sleep Over Typical Progression of Sleep Over the Course of the Nightthe Course of the Night

Reprinted with permission from Erman MK. J Clin Psychiatry. 2001;62(suppl 10):9-17.

REM = rapid eye movement.

Awake

REM

Stage 1

Stage 2

Stage 3

Stage 4

24 1 2 3 4 5 6 7WakeTime (h)


Dynamics of Sleep ArchitectureDynamics of Sleep Architecture

� First part of the night

� More slow wave sleep

� More parasympathetic tone

� More hemodynamically stable


Typical Progression of Sleep Over Typical Progression of Sleep Over the Course of the Nightthe Course of the Night

Reprinted with permission from Erman MK. J Clin Psychiatry. 2001;62(suppl 10):9-17.

REM = rapid eye movement.

Awake

REM

Stage 1

Stage 2

Stage 3

Stage 4

24 1 2 3 4 5 6 7WakeTime (h)


Dynamics of Sleep ArchitectureDynamics of Sleep Architecture

� Latter part of the night

� More REM sleep (sleep apnea is worse)

� More sympathetic tone

� More hemodynamically unstable


Sleep deprivation/fragmentation from any cause can contribute to:

1) Diminished endothelial function2) Increased BP If < 5 hours, 2 X risk of HTN

3) Insulin resistance decreased TST mimics DM

4) Increased risk of CAD (coronary art ds)

5) ObesityLeptin and Ghrelin

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Hormones that effect weight and appetite

• Leptin– From adipose cells (fat cells)

– Normally signals satiety = “makes you feel full”

Hormones that effect weight and appetite

• Ghrelin (GI tract)

• Signals increased appetite

• Signals you to “eat”

Sleep Deprivation, Hormones and Weight Gain

• Decreased Leptin– If less, then you “feel less full”

• Increased Ghrelin• If more, then “increases your appetite”

• Overall effect:

• less sleep = eat more = gain weight.

Prevalence of Sleep Apnea

• AHI > 5 – 29% men– 9 % women

• OSA (symptomatic)– 4% men– 2% women

Increases with age and menopause.

Stop-Bang Questionnaire

•• SSnoring•• TTiredness during daytime•• OObserved Apnea• High Blood PPressure•• BBMI > 35•• AAge > 50•• NNeck Circumference > 40cm (15.75 inches)• Male GGender

– Score > 3 merits further sleep evaluation

Timothy L. Grant, MD, FAASM

Ask Ask the patient (or bed partner):the patient (or bed partner):

� Do you snore, gasp, choke, 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?

� Do you have HTN, DM, CAD, CVD, DM?

A “yes” to any question may warrant further sleep evaluation.


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Obstructive Sleep Apnea (OSA): Manifestations

• Loud snoring• Excessive daytime sleepiness (EDS)• Awakenings: gasping, choking, snorting• Poor memory and concentration• Irritability or personality changes• Morning headache or confusion• Impotence, nocturia• Floppy eye lids• Edema

SDB,Predictive Historical Data

� Male gender� Ethnicity

� Age� Menopause

� Macroglossia, retrognathia� Obesity � Neck Circumference (16 in. women,17 men)

Rationale for Treating Sleep Apnea

1) Improved nocturnal sleep patterning

2) Awaken feeling more refreshed

3) Diminished Daytime Sleepiness


Rationale for Treating Sleep Apnea (cont.)Prevention of :

HypertensionCardiovascular DiseaseCerebrovascular DiseaseDiabetesDepression

– Nocturia– Sexual Dysfunction– Morning

Headaches– Gastroesophageal

Reflux– Cognitive

Impairment– Cancer


Cardiac Related Sequellae of OSA

�Coronary artery disease, MI�Cardiac arrhythmias

�CHF�Hypertension

�Pulmonary hypertension �Increased mortality


Sleep Apnea and Sleep Apnea and Metabolic SyndromeMetabolic Syndrome

Metabolic Syndrome X1) Hypertension

2) Glucose Intolerance3) Hyperlipidemia

4) Obesity

•Syndrome Z (Metabolic Syndrome + OSA)


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Normal PSG, supine, in REM


Obstructive Sleep Apnea

Timothy Grant, MD

Effects Of OSA

� Sleep Deprivation� Arousals from Sleep� Hypoxia� Hypercapnia� Sympathetic Activation� Negative Intrathoracic Pressure


Pathologic Changes with OSA

� Oxidative Stress� Inflammation (plasma cytokines,TNF,IL-6, CRP)

� Endothelial Dysfunction� Thin walled atrium gets stretched

� Hypercoagulable State� Impaired venous return to the heart� Metabolic Dysregulation


Probability of survival in patients with untreated OSA


Young T, et al: Sleep disordered breathing and mortality: Eighteen year follow up of the Wisconsin

Sleep Cohort Study. Sleep 31:1071-1078, 2008.

• Moderate to severe OSA, AHI>15

• Mild OSA 5-14 + comorbities/clinical sxs – HTN, CAD, Arrhythmias, CVD, DM– EDS, neurocognitive ds, mood disorder– Insomnia– High risk occupation

OSA: How to decide whom to treat.

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FOR ALL CPAP PATIENTS CONSIDER:

• General Sleep Hygiene. • Weight Loss.

• Off Back Positioning (positional tee shirt).

• Avoidance of nocturnal Etoh / sedation.*• Education as to risks of untreated SDB.

• Safety Issues regarding hypersomnolence.

• Compression stockings if edema

Oral AppliancesMandibular Advancement Devices

• Over 80 FDA approved devices• A new device available which can be adjusted

during PSG • For mild – moderate OSA• Risks of TMJ and altered dentition• Need appropriate dentist follow up • Need f/u PSG to validate efficacy

Surgical Options for OSA

• Septoplasty– May help snoring and airflow, but will not fully address OSA

• UPPP (Uvulopalatalpharyngoplasty)– Very uncomfortable and poor efficacy

• Maxillo-Mandibular advancement – Extensive procedure, more successful

• Tonsillectomy• Very beneficial in children, not adults

• Hypoglossal Nerve Stimulation – advances the tongue with each inspiration

Hypoglossal Nerve StimulationAKA: Sleep Apnea Pacemaker

Hypoglossal Nerve StimulationSleep Apnea Pacemaker

• STAR Clinical Trial – 126 patients, BMI < 32

– Moderate-severe OSA AHI 20-50– CPAP intolerant

• Eligible patients– Proven failure on CPAP– Special pharyngeal exam under anesthesia

• Excluded patients– Neuromuscular ds, hypoglossal nerve palsy– Severe COPD, mod-severe pulmonary hypertension – Heart disease or uncontrolled HTN– Active psychiatric disease

Strollo, et al, NEJM, STAR Clinical Trial

Sleep Apnea Pearls

1) OSA may persist w/o snoring or obesity2) Weight loss may help OSA even after subsequent

weight gain. 3) Rx of OSA may decrease visceral fat area even w/o

decrease in total body fat or subcutaneous fat. 4) Sildenafil citrate (Viagra) may exacerbate OSA.5) OSA incidence in women increases after menopause.6) Women may present with much more subtle symptoms

than men, and mimic insomnia.

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Tips on Increasing CPAP Compliance

� Patient and Family Education� CPAP Desensitization, CPAP Nap evaluation� Pressure change adjustment, Auto PAP , Servovent� Change mask, nasal pillows, fabric mask� Ramping � Heated Humidification, Climate line� Nasal steroids � Mild sedation (i.e. nonbenzodiazepine)� ENT evaluation for procedural intervention

CPAPcontinuous positive airway pressure

IPAP = EPAP


IPAP = inspiratory positive airway pressure

EPAP= expiratory positive airway pressure

AUTO PAP (CPAP)IPAP=EPAP=Adjusting


BIPAP (Bilevel)IPAP higher, EPAP lower


AUTO BIPAP (Bi-level)IPAP higher, EPAP lower, both adjusting


VPAP/SERVOVENTIPAP adjusts, EPAP stays the same


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Coronary Artery Disease and OSA

• Increased risk of cardiovascular ds. and MI • Recurrent hypoxia• Decreased coronary blood flow• Negative intrathoracic pressure• Systemic inflammation• Coagulopathy• Endothelial dysfunction


Day-Night Variation of Sudden Cardiac DeathMayo 7/87-7/03

• (midnight- 6 AM)– 46% OSA, 21% non OSA, 16% gen pop

• (6 AM- noon)– 20% OSA, 41% non OSA, 35% gen pop

• 12:00-17:59 (noon- 6 PM)– 9 % OSA, 26%, no OSA, 24% gen pop

• 18:00-23:59 (6 PM- midnight)– 24% OSA, 12% no OSA, 25% gen pop Kuniyoshi, et al, JACC 2008 52 (5): 343-

346

Day-night pattern of myocardial infarction

• (10 PM- 6 AM) – OSA > 40%, non OSA < 20%

• (6 AM- 2 PM)– OSA 20%, non OSA > 40%

• 14:00- 21:59 (2 PM- 10PM)– OSA 40%, non OSA 35%

Kuniyoshi, et al, JACC 2008 52 (5): 343-346

Sudden Cardiac DeathMyocardial Infarction

So, if you have untreated OSA…….

• More likely sudden cardiac death 12AM-6AM.

• More likely to have an MI 10PM-6AM.

Shifts to and from Daylight Savings Time .

• Spring “spring forward” (loss of hour)Increase risk of MI for days following

• Fall “fall back” (gain one hour)Decreased risk of MI for days following

– So, less sleep = more likely to have an MI.

Virend K. Somer,, MD, PhD, Sudden Cardiac Death, Mayo Clinic


Central Sleep Apnea

• Central Sleep Apnea (CSA/CSR)– No mechanical obstruction, open airway– No Effort to breath

CSA associated withCHFCerebrovascular diseaseOpiate usage High Altitude

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Obstructive Sleep Apnea

Timothy Grant, MD

Central Sleep Apnea

Timothy Grant, MD

Cheyne Stokes RespirationsA form of Central Sleep Apnea


Sleep Health Heart Study 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 40-70 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 women


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


CHF and OSA/CSA

• CSA common in CHF• OSA common as well in CHF

– Moderate-severe OSA in 26-51% of CHF pts.

• Increased mortality if CHF w/ OSA or CSA• Treatment of SDB (CPAP, BIPAP with back up

rate, Servovent/Adaptive PAP):– Decreases sympathetic activation

– Improves LVEF

– Improves exercise capacity

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Arrhythmias in OSA

� Bradycardia� Sinus pause

� Heart block� Ventricular ectopy and tachycardia

� Atrial fibrillation


Obstructive Sleep ApneaREM, 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 (increased sympathetic)

� 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

� 3 million persons in US with AF 2005.

� Epidemiologic studies suggest OSA is a risk factor for new onset AF.

� OSA may confer worse prognosis for recovery after atrial fibrillation.


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OSA and Atrial Fibrillation

� 30-50% of AF pts for cardioversion had OSA

� 80% AF recurrence post cardioversion if untreated OSA. more successful cardioversion (80% vs 40%)

� Increased AF post CABG if OSA

� Hypoxemia and obesity independent predictors of AF


OSA and HypertensionOSA 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%


CPAP Treatment of OSA

� Decreased Sympathetic arousals

� Normalizing dipping/nondipping

� Lowers BP

� Favorable effect on AF recurrence, esp after cardioversion


Pearls to Remember

Rationale for aggressive treatment of SDB• Improved QOL• Improved daytime sleepiness • Decreased MVA’s• Decreased visceral fat • Decreased inflammatory markers• Improved glycemic control• Decreased BP and CV events• Improved survival

Pearls to Remember

1) Consequences of OSA related to both arousals and hypoxia.

2) Arousals provoke sympathetic tone.3) OSA may exist without snoring.4) With difficult to control HTN and atrial

fibrillation, look for occult OSA.


Bibliography

• 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; 29:720-727.

• 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; 352:1206-1214.

• 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; 2007:575-581.• 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;

365:1046-1053.• 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;

31:1071-1078.• 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):1378-1384.


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Bibliography

• Becker HF: Systematic and pulmonary arterial hypertension in obstructive sleep apnea: Sleep Medicine Clinics: Sleep and Cardiovascular Disease. 2007, pp. 549-557

• Young T, Finn, Peppard, et al: Sleep-disordered breathing and mortality: Wisconsin Sleep Cohort. Sleep 31:1071-1078,2008.

• Lee Chong: Sleep Medine Clinics: Sleep and CVD. 2007, pp 549-557.

• Gottlieb, et al: Circulation,122:352-380, 2010.

• Fialkow J. Cardiovascular Disease and Sleep Apnea. Baptist Sleep Education Series, 4/12/2013

• Virend K. Somer,, MD, PhD, Sleep Apnea, Arrhythmias, and Sudden Cardiac Death, Mayo Clinic.

•


Bibliography

• Gami, et al., OSA and Risk of Incidental Atrial Fibrillation, JACC, 2007

• Gami, Howard,Olsen,Somers, Sudden Cardiac Death, NEJM, 2005

• Kuniyoshhi et al, Day-Night Variation of Acute Mycardial Infarction in Obstructive Sleep Apnea, JACC, 2008, 52(5):343=346

• Gangswisch, et al., Short sleep duration and obesity, Sleep , 2005

• Patel, et al., Epidemiologic evidence of sleep duration and obestity, Am J Epidemiology, 2006

• Buxton, et al, Sleep restriction reduces insulin sensitivity, Diabetes, 2010.

• Kasai T, et al: Prognosis of patients with heart failure and OSA treated with CPAP: Chest> 133:690-696, 2008.

Documents

Timothy L. Grant, MD,FAASMcme.baptisthealth.net/cvdprevention/documents/2015... · treatment on overall cardiovascular health. Timothy L. Grant, MD,FAASM Sleep Disordered Breathing