Sleep apnea and CVD: The need for collaboration
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Obstructive sleep apnea, or OSA, is a dangerous, chronic disease that involves the repeated collapse of the upper airway during sleep. A report commissioned by the American Academy of Sleep Medicine estimates that OSA affects nearly 30 million American adults, with an estimated 23.5 million of them currently undiagnosed. Untreated OSA has been linked to an increased risk for numerous health problems, and it is extremely common in people who have CVD.
Sleep apnea and CVD
Because many patients with CVD have comorbid OSA, cardiologists can play an important role in improving access to sleep care. Diagnosis and treatment of OSA is incredibly important for both sleep health and heart health.
Research suggests that as little as one night of severe OSA can impair the body’s ability to regulate BP. Therefore, it is no surprise that about 30% to 40% of individuals with high BP also have OSA. Even with aggressive medication use, severe OSA is still associated with poor BP control. It is estimated that OSA is present in up to 85% of people with treatment-resistant hypertension, making it the most common secondary cause of this pervasive problem.
Middle-aged men with severe OSA are 58% more likely to develop HF, the leading cause of hospitalization in Americans aged at least 65 years. The risk for atrial fibrillation is two to four times higher among those with OSA, and patients with untreated, severe OSA are eight times more likely to fail AF treatment.
Untreated, severe OSA more than doubles the risk for death from heart disease, so it is no exaggeration to state that the effective treatment of severe OSA can be lifesaving. A recent meta-analysis of 27 studies involving more than 3 million participants by Yiqun Fu, MD, medical doctor in the department of otolaryngology head and neck surgery and the Center of Sleep Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, and colleagues found that the risk for CV mortality was reduced to normal levels in patients with sleep apnea who were treated with continuous positive airway pressure (CPAP) therapy.
Untreated OSA is also associated with other metabolic and cerebrovascular problems. For example, approximately 7 in 10 individuals with type 2 diabetes have untreated OSA. Similarly, people with untreated, severe OSA are two times more likely to have a stroke, a major cause of severe disability and the fifth leading cause of death in the U.S.
Collaboration and care innovation
The American Academy of Sleep Medicine (AASM), of which I am president, is seeking to develop strategies to improve the diagnosis and treatment of OSA. In late 2018, the AASM hosted 35 representatives from 14 medical societies, nurse practitioner associations and patient advocacy groups for a 1-day Sleep-Disordered Breathing Collaboration Summit. Participants from groups such as the American College of Cardiology discussed ways to expand access to sleep care by connecting providers in a multidisciplinary, team-based approach.
Practice standards published by the AASM provide a comprehensive strategy for how physicians, including cardiologists, can screen for OSA and identify those who are at risk. A key risk factor is obesity, and high-risk patients include those with congestive HF, AF, treatment-refractory hypertension, type 2 diabetes, stroke, nocturnal dysrhythmias or pulmonary hypertension. Screening questions should inquire about a history of snoring and daytime sleepiness while evaluating for the presence of obesity, retrognathia and hypertension.
A comprehensive sleep history in a patient suspected of OSA should include an evaluation for snoring; witnessed apneas; gasping/choking episodes; excessive sleepiness not explained by other factors, including assessment of sleepiness severity using the Epworth Sleepiness Scale; total sleep amount; nocturia; morning headaches; sleep fragmentation/sleep-maintenance insomnia; and decreased concentration and memory. Physicians also should evaluate at-risk patients for secondary conditions that may occur as a result of OSA — including hypertension, stroke, MI, cor pulmonale and decreased daytime alertness.
The physical examination should include an assessment of the respiratory, CV and neurologic systems. Particular attention should be paid to the presence of obesity and signs of upper airway narrowing. Features that may suggest the presence of OSA include: increased neck circumference (> 17 inches in men, > 16 inches in women), BMI of at least 30 kg/m2, a modified Mallampati score of 3 (soft palate, base of uvula visible) or 4 (only hard palate visible), the presence of retrognathia, lateral peritonsillar narrowing, macroglossia, tonsillar hypertrophy, elongated/enlarged uvula, high-arched/narrow hard palate, nasal abnormalities and overjet, a condition in which the upper teeth protrude outward and sit over the bottom teeth.
Patients deemed to be at risk for OSA should have the diagnosis confirmed and severity determined with objective testing in an expedited manner to initiate treatment. Polysomnography is the standard diagnostic test for the diagnosis of OSA in adult patients in whom there is a concern for OSA. However, a home sleep apnea test with a technically adequate device can be used for the diagnosis of OSA in uncomplicated adult patients presenting with signs and symptoms that indicate an increased risk for moderate to severe OSA. This risk is indicated by the presence of excessive daytime sleepiness and at least two of the following three criteria: habitual loud snoring; witnessed apnea or gasping or choking; or diagnosed hypertension. Follow-up, under the supervision of a board-certified sleep medicine physician, ensures that study findings and recommendations are relayed appropriately and that appropriate expertise in prescribing and administering therapy is available to the patient.
Intertwined conditions
OSA and CVD are intertwined. Patients who have CVD should be screened for OSA with a comprehensive sleep evaluation, physical examination and a validated questionnaire such as STOP-Bang that identifies key warning signs and risk factors such as snoring, choking or gasping during sleep, fatigue or daytime sleepiness, obesity and high BP. Those patients with a confirmed risk for OSA can be referred to one of more than 2,600 AASM-accredited sleep facilities across the U.S. The AASM also continues to explore new models to advance sleep care by leveraging the expertise of other specialists such as cardiologists.
Because OSA hurts hearts, it is critical for cardiologists and sleep specialists to work collaboratively to reduce the burden of this sleep-related breathing disorder.
- References:
- American Academy of Sleep Medicine. Hidden health crisis costing America billions. 2016. Available at: aasm.org/advocacy/initiatives/economic-impact-obstructive-sleep-apnea. Accessed Feb. 11, 2020.
- Börgel J, et al. Eur Respir J. 2006;doi:10.1183/09031936.06.00131304.
- Epstein LJ, et al. J Clin Sleep Med. 2009;5:263-276.
- Fu Y, et al. Sleep Breath. 2017;doi:10.1007/s11325-016-1393-1.
- Gottlieb DJ, et al. Circulation. 2010;doi:10.1161/CIRCULATIONAHA.109.901801.
- Kapur VK, et al. J Clin Sleep Med. 2017;doi:10.5664/jcsm.6506.
- Luyster FS, et al. Sleep. 2012;doi:10.5665/sleep.1846.
- Pamidi S, et al. Front Neurol. 2012;doi:10.3389/fneur.2012.00126.
- Patel D, et al. Circ Arrhythm Electrophysiol. 2010;doi:10.1161/CIRCEP.109.858381.
- Tremblay JC, et al. Am J Physiol Heart Circ Physiol. 2016;doi:10.1152/ajpheart.00388.2016.
- Tung P, et al. J Atr Fibrillation. 2016;doi.org/10.4022/jafib.1283.
- Walia HK, et al. J Clin Sleep Med. 2014;doi:10.5664/jcsm.3946.
- Wang X, et al. Int J Cardiol. 2013;doi:10.1016/j.ijcard.2013.08.088.
- For more information:
- Kelly A. Carden, MD, MBA, is the president of the American Academy of Sleep Medicine and is board-certified in sleep medicine, internal medicine, pulmonary medicine and critical care. She is a practicing sleep medicine physician with Saint Thomas Medical Partners — Sleep Specialists in Nashville, Tennessee. She can be reached at 300 20th Ave. North, G8, Nashville, TN 37203; Twitter: @aasmorg.
Perspective
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Carl J. Pepine, MD, MACC
This is a very important topic for our patients with CVD, but unfortunately, many patients that I refer to our sleep center do not want to undertake a night in the center for a formal sleep study. Perhaps making more information available about the Home Sleep Study would help, particularly if this information were placed in our outpatient waiting rooms where patients could see it.
Collapse
American Academy of Sleep Medicine. Hidden health crisis costing America billions. 2016. Available at: aasm.org/advocacy/initiatives/economic-impact-obstructive-sleep-apnea.
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