Screening for Sleep Apnoea in Cardiac Rehabilitation 2 December 2018 Screening for Sleep Apnoea in Cardiac Rehabilitation Dr Frances WISE1, 2 Mary-Anne BEER1 Robyn SHEPPARD1 CARDIAC REHABILITATION UNIT, CAULFIELD HOSPITAL, ALFRED HEALTH EPWORTH MONASH REHABILITATION MEDICINE UNIT This morning, I would like to present to you the outcomes from a quality improvement program we introduced into our Cardiac Rehab Unit at Caulfield Hospital back in 2016 using a screening tool for obstructive sleep apnoea.

Obstructive Sleep Apnoea 2 December 2018 Obstructive Sleep Apnoea So what is obstructive sleep apnoea?

Obstructive Sleep Apnoea 2 December 2018 Obstructive Sleep Apnoea A disorder in which breathing is repetitively interrupted during sleep due to collapse of the upper airway resulting in hypoxia and sleep fragmentation. Sleep 1999 Obstructive sleep apnoea is disorder in which breathing is repetitively interrupted during sleep, due to collapse of the upper airway resulting in hypoxia and sleep fragmentation. It is associated with daytime sleepiness and is categorised as mild moderate or severe sleep apnoea when diagnosed using polysomnography or a sleep study. So why are we in the Cardiac Rehab Unit interested in obstructive sleep apnoea?

2 December 2018 Background Obstructive Sleep Apnoea (OSA) affects 25% of men and 9% of women in Australia Snore Australia Sleep apnoea affects 25% of men and 9% of women Australia wide, but it’s not only associated with daytime sleepiness, although this does have implications for work, safety and social interactions.

2 December 2018 Background Obstructive Sleep Apnoea is associated with significant chronic diseases Sleep apnoea is also associated with other chronic diseases including hypertension, AMI, stroke, diabetes, depression and may lead to early death. The associations of OSA are very similar to the risk factors of our patients with coronary artery disease and heart failure.

The relationship with cardiac risk factors 2 December 2018 The relationship with cardiac risk factors Prevalence of Obstructive Sleep Apnoea in Populations With Cardiovascular Disorders (CVD) Condition % Hypertension 30–83 Ischemic heart disease 30–58 Stroke 43–91 HF, with reduced ejection fraction 12–53 HF, with preserved ejection fraction 40 Hypertrophic cardiomyopathy Atrial fibrillation 25–80 End-stage renal disease 40–60 The relationship between OSA and cardiovascular disease is significant, as you can see on this table. The Australia wide figures for OSA I showed earlier are still considerably lower than their prevalence in patients with cardiovascular conditions, such as heart failure and IHD, but notably hypertension, stroke and atrial arrhythmias. There is also an increasing awareness of the importance of OSA’s role in the causation or promotion of these conditions. Floras 2014

2 December 2018 Thus, not surprisingly, OSA is recognised as a predictor of premature cardiovascular death. Floras 2014 So, it’s not surprising that OSA is a predictor of premature cardiovascular death.

WHY - did we undertake this study? 2 December 2018 “Patients with untreated sleep apnoea may experience significantly worse outcomes during their cardiac rehab and recovery” Sharma Parker 2011 OSA is underdiagnosed and undertreated in Cardiac Rehabilitation patients Why did we undertake this study? It has been documented that patients with untreated OSA may experience worse outcomes during their cardiac rehab and recovery. However, this condition is underdiagnosed and undertreated in our patient group.

HOW – did we perform this study? 2 December 2018 HOW – did we perform this study? 431 cardiac rehabilitation patients completed: the Berlin Sleep Questionnaire (BSQ), We also measured: Hospital Anxiety and Depression Scale 6 Minute Walk Test (6MWT). Body Mass Index (BMI), Body Fat % and Risk factor history So what did we do? We gave the Berlin Sleep Questionnaire to 431 of our Cardiac Rehab patients on their admission to the unit. Each patient completed the Hospital Anxiety and Depression Scale Questionnaire and 6MWT on admission and discharge. We looked at their BMI and body fat percentage and each patient had a risk factor profile completed.

HOW – did we perform this study? 2 December 2018 HOW – did we perform this study? Berlin Sleep Questionnaire Netzer 1999 The Berlin Sleep Questionnaire is a 10 point self report questionnaire, divided into 3 categories. It covers snoring, daytime fatigue and the final category covers both hypertension and obesity. If a patient scores high in 2 or more of these categories, they are considered high risk for Obstructive Sleep Apnoea

HOW – did we perform this study? 2 December 2018 HOW – did we perform this study? Score ≥ 2 on the BSQ = letter to GP to suggest FURTHER INVESTIGATION Berlin Sleep Questionnaire and their GP was sent a letter requesting they consider a referral for further investigation, or referral to a sleep clinic.

2 December 2018 Next Steps? The Berlin Sleep Questionnaire is only one screening tool that is freely available for screening for OSA. The Berlin Sleep Questionnaire is only one screening tool that is freely available, and should others consider screening for OSA there are other options available, but the Berlin was our screening tool of choice. So what did we find?

2 December 2018 WHAT – were the results? 38% (n = 164) of patients scored highly on BSQ & needed referral to a sleep clinic for follow up So what did we find? We found that 38% or 164 of our original 431 patients scored high risk on the Berlin Sleep Questionnaire. High Scorers Low Scorers AGE, MEAN 63.7 63.6 SEX, MALE, % 72.2 77 SMOKER, % 13.4* 9 HYPERTENSION, % 68.9* 42 DIABETES, % 28.4* 17.7 BMI, MEAN 30.2* 26.9 % BODY FAT, MEAN 31.2* 27.1 WAIST MEASURE, MEAN, CM 104.5* 97 HADS, % WITH ANXIETY 35.5* 21.7 HADS, % WITH DEPRESSION 32.2* 13.8 EXERCISE >150MINS/WEEK, % 54.2 57.7 6 MINUTE WALK, M, ADM 478* 501 6 MINUTE WALK, M, DC 634.7* 717

WHAT – were the results? Prevalence of Risk Factors in High Scorers 2 December 2018 High Scorers (164) Low Scorers (267) AGE, MEAN 63.7 63.6 GENDER MALE % 72.2 77 SMOKER % 13.4 * 9 HYPERTENSION % 68.9 * 42 DIABETES % 28.4 * 17.7 NECK CM MEAN 40.9 * 38.5 BMI, MEAN 30.2 * 26.9 % BODY FAT, MEAN 31.2 * 27.1 WAIST CM, MEAN 104.5 * 97 HADS ANXIETY % 35.5 * 21.7 HADS DEPRESSION % 32.2 * 13.8 EXERCISE >150 Mins/WK % 54.2 57.7 6 MWT MEAN ADM 478 * 501 6 MWT MEAN DISCH 634.7 * 717 These 431 patients all have a cardiac history and associated risk factors, however, when we compared these high risk sleep apnoea patients or “high scorers” with those who had a lower risk or “low scorers”, it revealed some interesting results. There is no statistical difference between age or gender in either group. The age and gender mix are comparable to that of our usual cardiac rehab population at Caulfield.

WHAT – were the results? Smoking is an independent risk factor for OSA 2 December 2018 WHAT – were the results? Smoking is an independent risk factor for OSA Smokers have a THREE fold increase in risk of developing OSA compared to non smokers Prevalence of smoking in sleep apnoea patients may be as high as 35% Kashyap 2001 “Where there’s smoke, there’s sleep apnoea!” Krishnan et al 20 We are all aware of the significant risk smoking poses to our cardiovascular health, but smoking is also an independent risk factor for OSA. In fact smokers also have a risk 3 times greater than non smokers of developing OSA. One study also showed the prevalence of smoking in sleep apnoea patients to be as high as 35%. To quote one researcher who claimed “Where there’s smoke, there’s sleep apnoea!”

WHAT – were the results? Prevalence of Risk Factors in High Scorers 2 December 2018 Prevalence of Risk Factors in High Scorers High Scorers (164) Low Scorers (267) AGE, MEAN 63.7 63.6 GENDER MALE % 72.2 77 SMOKER % 13.4 * 9 HYPERTENSION % 68.9 * 42 DIABETES % 28.4 * 17.7 NECK CM MEAN 40.9 * 38.5 BMI, MEAN 30.2 * 26.9 % BODY FAT, MEAN 31.2 * 27.1 WAIST CM, MEAN 104.5 * 97 HADS ANXIETY % 35.5 * 21.7 HADS DEPRESSION % 32.2 * 13.8 EXERCISE >150 Mins/WK % 54.2 57.7 6 MWT MEAN ADM 478 * 501 6 MWT MEAN DISCH 634.7 * 717 As you can see, our data supports this as the greater percentage of our patients who are current smokers also have a significantly higher risk of having sleep apnoea.

WHAT – were the results? Hypertension is a key risk factor for CVD 2 December 2018 WHAT – were the results? Hypertension is a key risk factor for CVD In the medical literature a third or more of individuals with hypertension also will have OSA . Floras 2015 Hypertension too is a key risk factor for CVD. In the medical literature, a third or more of individuals with hypertension will also have OSA

WHAT – were the results? Prevalence of Risk Factors in High Scorers 2 December 2018 High Scorers (164) Low Scorers (267) AGE, MEAN 63.7 63.6 GENDER MALE % 72.2 77 SMOKER % 13.4 * 9 HYPERTENSION % 68.9 * 42 DIABETES % 28.4 * 17.7 NECK CM MEAN 40.9 * 38.5 BMI MEAN 30.2 * 26.9 % BODY FAT MEAN 31.2 * 27.1 WAIST CM, MEAN 104.5 * 97 HADS ANXIETY % 35.5 * 21.7 HADS DEPRESSION % 32.2 * 13.8 EXERCISE >150 Mins/WK % 54.2 57.7 6 MWT MEAN ADM 478 * 501 6 MWT MEAN DISCH 634.7 * 717 Our results too reflect this. In fact 68.9% of our high scorers had diagnosed hypertension compared to 42% the low scorer group.

2 December 2018 WHAT – were the results? Intermittent hypoxia and sleep fragmentation can lead to insulin resistance Hamilton Naughton 2013 Large published studies indicate that OSA is a predictor of diabetes, with OSA patients 30% more likely to develop diabetes. Kendzerska et al 2014 Patients with diabetes have an increased risk of developing OSA Intermittent hypoxia and sleep fragmentation can lead a whole host of metabolic conditions including insulin resistance. Large studies indicate that OSA is a predictor of diabetes with OSA patients 30% more likely to develop diabetes. Conversely, patients with diabetes have an increased risk of developing OSA.

WHAT – were the results? Prevalence of Risk Factors in High Scorers 2 December 2018 High Scorers (164) Low Scorers (267) AGE, MEAN 63.7 63.6 GENDER MALE % 72.2 77 SMOKER % 13.4 * 9 HYPERTENSION % 68.9 * 42 DIABETES % 28.4 * 17.7 NECK CM MEAN 40.9 * 38.5 BMI, MEAN 30.2 * 26.9 % BODY FAT, MEAN 31.2 * 27.1 WAIST CM, MEAN 104.5 * 97 HADS ANXIETY % 35.5 * 21.7 HADS DEPRESSION % 32.2 * 13.8 EXERCISE >150 Mins/WK % 54.2 57.7 6 MWT MEAN ADM 478 * 501 6 MWT MEAN DISCH 634.7 * 717 As you can see, 28.4% of our high scorers were also found to have diabetes compared to 17.7% of low scorers.

2 December 2018 WHAT – were the results? The external and internal neck circumferences and the degree of obesity are important predictors of sleep apnoea Katz 1989 In general, the physical examination is normal in patients with OSA, aside from the presence of obesity (body mass index: >30 kg/m2), an enlarged neck circumference (men: >43 cm [17 in]; women: >37 cm [15 in]). Downey 2018 It has been well documented that neck circumference is a relevant factor in the diagnosis of OSA. The combination of obesity and a neck circ of greater than 43cm in men and greater than 37 cm in women are considered predictive.

WHAT – were the results? Prevalence of Risk Factors in High Scorers 2 December 2018 High Scorers (164) Low Scorers (267) AGE MEAN 63.7 63.6 GENDER MALE % 72.2 77 SMOKER % 13.4 * 9 HYPERTENSION % 68.9 * 42 DIABETES % 28.4 * 17.7 NECK CM MEAN 40.9 * 38.5 BMI MEAN 30.2 * 26.9 % BODY FAT MEAN 31.2 * 27.1 WAIST CM MEAN 104.5 * 97 HADS ANXIETY % 35.5 * 21.7 HADS DEPRESSION % 32.2 * 13.8 EXERCISE > 150 MINS/WK% 54.2 57.7 6 MWT ADM MEAN 478 * 501 6 MWT DISCH MEAN 634.7 717 Again our data supports this with our high scorers measuring a mean neck circumference of 40.9 cm compared to 38.5 cm in the low scorers.

2 December 2018 WHAT – were the results? Obesity is a major risk factor for both cardiovascular disease and OSA Wong et al 2018 A 10% weight gain can lead to a SIX fold increase in the chances of developing OSA Peppard Young Palta 2000 Obesity is also a major risk factor for both cardiovascular disease and OSA, with one study identifying a 10% weight increase may lead to a 6 fold increase in the chances of developing OSA.

WHAT – were the results? Prevalence of Risk Factors in High Scorers 2 December 2018 High Scorers (164) Low Scorers (267) AGE, MEAN 63.7 63.6 GENDER MALE % 72.2 77 SMOKER % 13.4 * 9 HYPERTENSION % 68.9 * 42 DIABETES % 28.4 * 17.7 NECK CIRCUMFERENCE CM MEAN 40.9 * 38.5 BMI MEAN 30.2 * 26.9 % BODY FAT MEAN 31.2 * 27.1 WAIST CM MEAN 104.5 * 97 HADS ANXIETY % 35.5 * 21.7 HADS DEPRESSION % 32.2 * 13.8 EXERCISE > 150 MINS/WEEK % 54.2 57.7 6 MWT ADM 478 * 501 6 MWT DISCH 634.7 * 717 As you can see from the mean BMI, mean body fat percentage and corresponding mean waist measurement, our obese patients have a statistically significant increase in risk for OSA compared to our lower weight patients.

2 December 2018 WHAT – were the results? Sleep disturbance is strongly associated with depressive symptoms and health related quality of life Banack 2014 Patients with both depression and OSA have an increased risk of death/adverse events following myocardial infarction, more than either depression or OSA alone. Hayano et al 2012 Sleep disturbance is strongly associated with depressive symptoms and health related quality of life and Patients with both depression and OSA have an increased risk of death/adverse events following myocardial infarction, more than either depression or OSA alone.

WHAT – were the results? Prevalence of Risk Factors in High Scorers 2 December 2018 High Scorers (164) Low Scorers (267) AGE MEAN 63.7 63.6 GENDER MALE % 72.2 77 SMOKER % 13.4 * 9 HYPERTENSION % 68.9 * 42 DIABETES % 28.4 * 17.7 NECK CM MEAN 40.9 * 38.5 BMI MEAN 30.2 * 26.9 %BODY FAT MEAN 31.2 * 27.1 WAIST CM MEAN 104.5 * 97 HADS ANXIETY % 35.5 * 21.7 HADS DEPRESSION % 32.2 * 13.8 EXERCISE > 150 MINS/WEEK % 54.2 57.7 6 MWT ADM 478 * 501 6 MWT DISCH 634.7 * 717 The percentage of our patients with increased anxiety and depression indicating a poorer health related QoL, were also significantly represented in the high scorer category.

2 December 2018 WHAT – were the results? Health related quality of life influences both compliance with medical treatments and program adherence Banack 2014 OSA is associated with impaired exercise capacity and lower peak VO2. Beitler et al 2014 Health related quality of life influences both compliance with medical treatments and program adherence, which is particularly important for our patients in the CRU as they manage their risk factors. For example exercise…OSA is associated with impaired exercise capacity and lower peak VO2.

WHAT – were the results? Prevalence of Risk Factors in High Scorers 2 December 2018 High Scorers (164) Low Scorers (267) AGE MEAN 63.7 63.6 GENDER MALE % 72.2 77 SMOKER % 13.4 * 9 HYPERTENSION % 68.9 * 42 DIABETES % 28.4 * 17.7 NECK CM MEAN 40.9 * 38.5 BMI MEAN 30.2 * 26.9 %BODY FAT MEAN 31.2 * 27.1 WAIST CM MEAN 104.5 * 97 HADS ANXIETY % 35.5 * 21.7 HADS DEPRESSION % 32.2 * 13.8 EXERCISE > 150 MIN/WEEK % 54.2 57.7 6 MWT ADM 478 * 501 6 MWT DISCH 634.7 * 717 Whilst not statistically significant, there was a trend towards fewer exercise minutes completed per week by our high scorers than our low scorers. What is significant however, is the improvement on 6 MWT from admission to discharge, where our low scorers had a mean improvement of 216 metres, whilst the high scorers, had a mean improvement of only 157 metres on discharge.

WHAT – were the results? To Summarise: HIGH SCORERS: 2 December 2018 WHAT – were the results? To Summarise: HIGH SCORERS: Were significantly more likely to have a history of smoking, hypertension or diabetes. Had Higher BMI, body fat % and neck circumference higher prevalence of depression and anxiety. Had Lower Exercise Tolerance and there was less improvement in 6MWT by discharge. In summary, our high risk patients were significantly more likely to have a history of smoking, hypertension or diabetes. They had higher BMI, body fat percentage neck circumference. There was also an increased prevalence of anxiety and depression. They also had poorer outcomes on their 6MWT on discharge.

WHAT – were the results? Of our 164 high scorers, 2 December 2018 WHAT – were the results? Of our 164 high scorers, only 5 patients were referred by their GPs for further investigation. Unfortunately, of our 164 high scoring patients, only 5 of these high scorers were referred by their GP to a sleep clinic.

2 December 2018 Our Unit is developing a protocol to initiate direct referral to sleep clinics, with examination of outcomes including Quality of Life, fat mass and mood. Next Steps? As a result, our team in the CRU are developing a protocol to directly refer these patients to a sleep clinic to help improve their outcomes and their quality of life.

2 December 2018 THANK YOU!