Dr S.M.HAMMAD RIZVI Dr JAIRO LOPEZ PREVELANCE OF SYMPTOMS OF SLEEP APNEA AND ITS RELATIONSHIP TO HYPERTENSION IN FCC PATIENTS Dr S.M.HAMMAD RIZVI Dr JAIRO LOPEZ

SLEEP APNEA The Greek word “APNEA” literally means “without breath” There are three types of apnea: obstructive, central, and mixed; of the three, obstructive is the most common. Affects more than twelve million Americans, according to the National Institutes of Health.

SLEEP APNEA OSA is defined as an average of at least 10 apneic and hypopneic episodes (≥10 sec) per sleep hour. It is a common sleep-related breathing disorder that leads to excessive daytime sleepiness because of marked fragmentation of sleep.

SLEEP APNEA COMMON SYMPTOMS Disrupted sleep Nocturnal gasping and choking Witnessed apnea Daytime sleepiness and fatigue Crowded posterior airway Short, thick neck Loud snoring

SLEEP APNEA Untreated, sleep apnea can cause high blood pressure and other cardiovascular disease, memory problems, weight gain, erectile dysfunction, and headaches. About 1/2 of patients who have essential hypertension have OSA, and about 1/2 of patients who have OSA have essential hypertension. Evidence shows that OSA is a major contributing factor for HTN.

SLEEP APNEA Lack of awareness by the public and healthcare professionals, the vast majority remain undiagnosed and therefore untreated. Despite many patients having clear symptoms of OSA, an estimated 80 to 90 percent of cases are undiagnosed.

More commonly, airway obstruction occurs in the oropharynx

OBJECTIVES To demonstrate how commonly OSA symptoms occur in a patient population of the FCC at the RCRMC. To see what percentage of patients with symptoms of OSA have essential HTN and demonstrate a relationship between the 2 disorders. To demonstrate that there is not documented clinical notes and assessments for patients with symptoms of OSA.

METHODS A survey was conducted using a questionnaire about sleep apnea symptoms given randomly to adult patients coming to FCC, in a period of 3 months. A subsequent chart review was done to see if patients were evaluated for sleep apnea or not and to look for comorbidities, emphasizing HTN.

SURVEY SAMPLE 234 patients filled out the questionnaire, ages: 18 and above. 29 patients were excluded because they did not fill out the questionnaire appropriately (eg. incomplete answers). Two minors who filled the survey were also excluded. A total of 203 patients were included and their respective charts were reviewed.

QUESTIONNAIRE 1. Do you snore loudly?Yes __No __ 2. Does your bedroom partner complain about your snoring?Yes __No __ 3. Does your snoring wake you up at night?Yes __No __ 4. Do you or your bedroom partner notice that you make gasping and choking noises during sleep?Yes __No __ 5. Do you have a dry mouth, sore throat or headache in the morning?Yes __No __ 6. Do you often fall asleep during the daytime when you want to stay awake?Yes __No __ 7. Are you often tired during the day?Yes __No __ 8. Do you have high blood pressure?Yes __No __ Suggested questionnaire from Victor LD. Obstructive sleep apnea in primary care. Dearborn, Mich.: Oakwood Hospital, 1997.

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CONCLUSIONS Patients are frequently not diagnosed despite of being symptomatic, because physicians do not routinely look for the disorder. When physicians are informed about the disorder, their index of suspicion is high and they routinely ask their patients about OSA symptoms (Haponik EF, Frye AW, Richards B, Wymer A, Hinds A, Pearce K, et al. Sleep history is neglected diagnostic information. Challenges for primary care physicians. J Gen Intern Med 1996;11:759-61)

CONCLUSIONS This increases the numbers of patients diagnosed and treated by about eightfold. (Ball EM, Simon RD Jr., Tall AA, Banks MB, Nino-Murcia G, Dement WC. Diagnosis and treatment of sleep apnea within the community. The Walla Walla Project. Arch Intern Med 1997;157:419-24) Therefore more awareness and education are needed for healthcare professionals to identify and treat this order.

CONCLUSIONS Physicians should be able to seek the diagnosis of obstructive sleep apnea by asking patients (especially those with HTN, obesity) simple sleep-related questions about snoring, excessive daytime sleepiness and reports of witnessed apneic events. OSA questionnaires are a valuable screening tool that allow physicians to evaluate the need for further evaluation and know what patients are at higher risk.

CONCLUSIONS The role of OSA in the production of EH is not frequently appreciated by FPs. A high BMI (>25) plus a positive questionnaire for OSA are sensitive parameters that indicate what patients are at higher risk. Diagnosing OSA adequately and treating it, help treat comorbidities more effectively, especially HTN, arrhythmias, GERD and patient’s quality of life in general.

CONCLUSIONS Comparing the high risk patients (eg. positive questionnaire, overweight or obese, hypertensive) with polysomnography results can help identify the prevalence of patients with the diagnosis of OSA. This can be an object of future studies in our patient population.

RECOMMENDATIONS Because OSA is a relatively frequent health problem and often misdiagnosed, it should be addressed effectively by family physicians, since treatment of the disorder decreases morbidity and mortality in pts. Sleep-related questions can be routinely asked to patients that are seen in clinic. The screening can take just a minute. (3 basic questions)

RECOMMENDATIONS 3 BASIC QUESTIONS 1. SNORING, how often, how loud, what position (may ask partner, tape recorder) 2. EXCESSIVE DAY TIME SLEEPINESS 3. EPISODES DURING SLEEP WHEN BREATHING STOPS (partner)

RECOMMENDATIONS When patients are finally diagnosed with OSA, they have had obvious symptoms of the disorder for an average of seven years, during which time they report having seen a family physician about 17 times and a subspecialist about nine times. (Rahaghi F, Basner RC. Delayed diagnosis of obstructive sleep apnea: Don't ask, don't tell. Sleep & Breathing 1999;3:119-24) The most likely reason for missed diagnosis is that physicians simply do not suspect sleep apnea.

RECOMMENDATIONS Besides medication and life style modifications, in order to improve BP control in hypertensive patients, a possible OSA diagnosis should be ruled-out, especially in overweight/obese patients. Documentation of assessments for symptoms of OSA by the FP’s is not routinely present in the clinic charts. It should be always written.

CPAP

REFERENCES American Family Physician, Vol. 65/No. 2 (January 15, 2002) Emedicine Obstructive Sleep Apnea Synd. by Timothy D. Murphy MD (Feb/2007) American Family Physician, Vol. 60/No. 8 (November 15, 1999) Indian J Med Res 124, Sep 2006, pp 281-290