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Obstructive sleep apnea combined with excessive sleepiness increases heart failure risk
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Patients with obstructive sleep apnea who were excessively sleepy were at higher risk for heart failure, according to findings recently published in the American Journal of Respiratory Care Medicine.
“To understand the clinical relevance of [obstructive sleep apnea] symptom subtypes, it is crucial to verify their association with relevant outcomes. Towards this end, recent work within the Icelandic Sleep Apnea Cohort found that symptom subtypes benefit in different ways with regard to symptom changes after 2 years of treatment with continuous positive airway pressure,” Diego R. Mazzotti, PhD, of the division of sleep medicine at the University of Pennsylvania Perelman School of Medicine, and colleagues wrote. “Currently, however, it is unknown whether these symptom subtypes have different long-term health consequences, particularly with respect to cardiovascular disease.”
Researchers evaluated the link between the symptom subtypes of moderately sleepy, minimally symptomatic, disturbed sleep and excessively sleepy, and the prevalence of overall CVD, coronary heart disease, heart failure and stroke in 1,207 patients with obstructive sleep apnea.
Mazzotti and colleagues found that patients who were defined as excessively sleepy had more than a threefold increased risk for prevalent heart failure vs. patients with the other sleep-related subtypes. Symptom subtype was also associated with incident CVD (P < .001), coronary heart disease (P = .015) and heart failure (P = .018), with the patients defined as excessively sleepy again showing increased risk vs. the other subtypes. There were no significant associations with prevalent CVD found.
“This concept should be introduced into routine clinical practice, by developing appropriate and validated clinical support tools and training clinicians in identifying the subtype at increased risk,” Mazzotti and colleagues wrote. “At the most basic level, clinicians should recognize that patients with reports of multiple sleepiness-related symptoms and a very high [Epworth Sleepiness Scale] score are more likely to have cardiovascular consequences due to their obstructive sleep apnea. The notion of obstructive sleep apnea as a heterogeneous disorder is firmly established and should lead to new insights into the ways in which specific patients benefit from treatment, improving efficiency of clinical trials and facilitating personalized medicine approaches.” – by Janel Miller
Disclosures: Healio Primary Care Today was unable to determine the authors’ relevant disclosures prior to publication.
Perspective
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Michael A. Grandner, PhD, MTR, CBSM
Sleep is an important part of health, and undertreated sleep disorders are an important public health problem. Sleep problems should not be excused away, especially if they result in daytime sleepiness.
There is a lot of discussion about real-world connections between obstructive sleep apnea and CVD. The links between CVD and severe obstructive sleep apnea are pretty clear, especially if untreated. The links with more moderate disease (which was a significant portion of the patients included in this study) is less well-known. It is commonly thought that the experience of daytime sleepiness and/or disturbed sleep at night is a sign of something particularly troublesome. This study showed that those with excessive sleepiness on top of their obstructive sleep apnea were at the greatest risk for CVD comorbidities. Of note, this group was also the most severely obese, with a higher average BMI. This is consistent with previous work and makes sense when fatigue is very common in these patients. It was surprising, though, that especially disturbed sleep was not necessarily associated with worse outcomes. However, the studies that look at overlap between insomnia and obstructive sleep apnea generally focus more on mental health outcomes. If patients with obstructive sleep apnea are experiencing excessive sleepiness, physicians should go out of their way to help them use their treatments to minimize the impact. Also, they should be monitored closely for the development of other cardiovascular problems.
Mazzotti and colleagues’ findings highlight the importance of patient experience with sleep apnea. Those that are excessively sleepy are at the highest risk for associated heart problems. This is not very surprising, but it is definitely informative and helpful in managing patients. It is important to note that patients who are experiencing a lot of sleepiness might be likely to use their CPAP treatments, which may make this whole situation worse.
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