1. Sleep Apnea in the Cardiac Patient Stephen Jennison

2. What is the impact of Sleep apnea on cardiovascular disease? Which came first: sleep apnea or CV disease?Which came first: sleep apnea or CV disease? More research is needed per AHA and ACCMore research is needed per AHA and ACC Difficult to decide impact due to multiple co-Difficult to decide impact due to multiple co- morbidities of obesity, diabetes and metabolic syndrome morbidities of obesity, diabetes and metabolic syndrome

4. SDB Impact on the Cardiovascular System Both OSA & CSA occur commonly in patients with cardiovascular disease and HF and may contribute to disease progression.Both OSA & CSA occur commonly in patients with cardiovascular disease and HF and may contribute to disease progression.

6. Sympathetic Activation Wakefulness Sleep Arousal & Hyperventilation O 2 & CO 2 Sympathetic Activation Airway Patency Compensation Airway Collapse Decreased Compensation O 2 & CO 2 Increased RR Increased mental activity Increased BP HR Increased Increased release of glucose

8. OSA Impacts: Sympathetic Nerve Activity, Blood Pressure, Oxygenation etc. OSA 250 125 0 BP RESP Sympathetic Nerve Activity Somers VK et al. J Clin Invest. 1995;96:1897.

9. Studies Linking OSA and Cardiovascular Disease

10. Prevalence of Sleep Disordered Breathing in Cardiovascular Disease 30% of cardiac disease patients30% of cardiac disease patients –Schafer et al, Cardiology 1999 50% of heart failure patients50% of heart failure patients –Javaheri, Circulation 1998 40% pts with systolic HF40% pts with systolic HF 50% pts with diastolic HF50% pts with diastolic HF 30% of hypertensive patients30% of hypertensive patients –83% of refractory hypertension Logan et al, J Hypertension 2001Logan et al, J Hypertension 2001

11. 40- 60% of patients with HTN have OSA 240- 60% of patients with HTN have OSA 2 –85% of patients with Resistant Hypertension on 3 or more meds have OSA Even mild OSA is a risk factor for hypertension 3, 6Even mild OSA is a risk factor for hypertension 3, 6 Patients with untreated OSA may be resistant to their anti-hypertensive medications 4Patients with untreated OSA may be resistant to their anti-hypertensive medications 4 Even small decreases in blood pressure may help to decrease the risk of heart attack and stroke 5Even small decreases in blood pressure may help to decrease the risk of heart attack and stroke 5 ¹Silverberg, et al., Curr Hypertens R 2001 2 Kraicze, et al., AJRCCM 2000 3 Bixler, et al., Arch Intern Med 2000 4 Logan, et al., J Hypertens 2001 5 Heinrich, et al., Circulation 2002 6 Neito, et al., Jama 2000 Association Between OSA & Hypertension

12. New England Journal of Medicine, 2000 Peppard et al

13. Hypertension Guidelines Recommendation by Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7):Recommendation by Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7): –Sleep Apnea listed identifiable cause of Hypertension –All newly diagnosed patients should be screened for Sleep Apnea –All patients with refractory hypertension should be screened for Sleep Apnea Chobanian, AV et al., J Hypertens 2003; 42: 1206- 1252

14. Association Between OSA & Heart Failure 37% of 450 HF patients had OSA37% of 450 HF patients had OSA –Also high incidence of Central or Mixed apneas Risk factors for OSA in HF includedRisk factors for OSA in HF included –BMI > 35 in males –Age > 60 in females Sin et.al, Am J Respir Crit Care Med 1999; 160: 1101- 1106 Work by Sin, et al., 2000

15. The prevalence of arrhythmias was compared in two samples of participants from the Sleep Heart Health StudyThe prevalence of arrhythmias was compared in two samples of participants from the Sleep Heart Health Study –228 subjects with sleep- disordered breathing (RDI > 30) vs. 338 subjects without sleep- disordered breathing (RDI 30) vs. 338 subjects without sleep- disordered breathing (RDI < 5) Individuals with severe sleep-disordered breathing have two to fourfold higher odds of complex arrhythmias than those without sleep-disordered breathing even after adjustment for potential confounders.Individuals with severe sleep-disordered breathing have two to fourfold higher odds of complex arrhythmias than those without sleep-disordered breathing even after adjustment for potential confounders. Association Between OSA & Arrhythmias Mehra R, et.al. Am J of Respir Crit Care Med 2006 Vol. 173: 910-916 Shaded bar: pts with OSA White bar: pts. without OSA

16. ACC/AHA HFSA Heart Failure Guidelines Recommendation by American College of Cardiology, American Heart Association and the Heart Failure Society of America :Recommendation by American College of Cardiology, American Heart Association and the Heart Failure Society of America : –Sleep Apnea listed identifiable cause of Heart Failure –It is recommended that all newly diagnosed patients be screened for Sleep Apnea –Patients refractory to treatment for Heart Failure should be screened for Sleep Apnea Hunt, et.al. ACC/AHA 2005 Guidelines: Circulation:2005:112

17. The Impact of Untreated OSA on Cardiovascular System

18. Cardiovascular mortality and morbidity in OSA Study of 1651 Men, over 10 yearsStudy of 1651 Men, over 10 years –264 Normal (control group) –377 Snorers (AHI<5) –403 Untreated Mild-Mod OSA (AHI 5 – 30 without EDS) –235 Untreated Severe OSA (AHI > 30 or AHI> 5 with EDS) –372 Severe OSA with CPAP Treatment OSA (AHI > 30, CPAP > 4hrs/day) CPAP compliance objectively measuredCPAP compliance objectively measured Study Fatal and Non-Fatal Cardiac EventsStudy Fatal and Non-Fatal Cardiac Events Marin, JM et. al Lancet 2005: 365:1046 - 1053

19. Fatal CV Events over 10 year period Marin, JM et. al Lancet 2005: 365:1046 - 1053

20. Non-Fatal CV Events per group Marin, JM et. al Lancet 2005: 365:1046 - 1053

21. Outcomes of Study Patients with severe OSA that was left untreated had a significant increase in CV events (both fatal or non-fatal events) after 10 yearsPatients with severe OSA that was left untreated had a significant increase in CV events (both fatal or non-fatal events) after 10 years –Risk factor: 2.87 higher than norms Patients with severe OSA had a significant reduction in CV events when treated with CPAPPatients with severe OSA had a significant reduction in CV events when treated with CPAP –Patients who used CPAP > 4 hours per night had a drop in CV risk Marin, JM et. al Lancet 2005: 365:1046 - 1053

22. Treatment of OSA & Refractory HTN 16 of 19 refractory HTN patients had underlying OSA16 of 19 refractory HTN patients had underlying OSA 11 patients participated in CPAP trial11 patients participated in CPAP trial CPAP titrated to approx. 9 cm H 2 0CPAP titrated to approx. 9 cm H 2 0 Blood pressure and baroreflex sensitivity were studied on and off CPAPBlood pressure and baroreflex sensitivity were studied on and off CPAP 24-hour blood pressure was evaluated at baseline and after 2 months of CPAP therapy24-hour blood pressure was evaluated at baseline and after 2 months of CPAP therapy Logan AG., et al., Eur Respir J 2003; 21: 241-247Logan AG., et al., Eur Respir J 2003; 21: 241-247

23. Results: CPAP group: Approximate 10mmHg drop in mean blood pressureCPAP group: Approximate 10mmHg drop in mean blood pressure –predicts a 37% reduction in risk for CHD –56% reduction in risk for stroke No relevant change in blood pressure occurred with sub- therapeutic CPAPNo relevant change in blood pressure occurred with sub- therapeutic CPAP

25. Screening in Hospital Sleep apnea is found in at least 50% of patients with CHFSleep apnea is found in at least 50% of patients with CHF Heart Failure nurses should screen for sleep apnea in all CHF patientsHeart Failure nurses should screen for sleep apnea in all CHF patients Referral to sleep disorder teamReferral to sleep disorder team Outpatient sleep study per MD orderOutpatient sleep study per MD order All cardiac patients in outpatient Cardiology clinic should be screened with Epworth Sleepiness tool

27. Results: Treatment of OSA & Refractory HTN PopulationPre-CPAP On CPAP p value AHI (hr -1 sleep) 45.3±10.12.2±0.5<0.01 Arousal Index (hr -1 sleep) 37.1±5.99.4±1.6<0.001 Lowest SaO 2 (%) 83.3±1.192.1±0.7<0.0001 Logan AG., et al., Eur Respir J 2003; 21: 241-247

29. Hallmark OSA Signs and Symptoms Excessive daytime sleepiness (EDS) unexplained by other factorsExcessive daytime sleepiness (EDS) unexplained by other factors with with Loud disruptive snoringLoud disruptive snoring or or Nocturnal choking/gasping/snortingNocturnal choking/gasping/snorting or or Nocturnal pauses in breathingNocturnal pauses in breathing

30. Additional Signs/Symptoms of OSA Recurrent nocturnal awakeningsRecurrent nocturnal awakenings Un-refreshing sleepUn-refreshing sleep Daytime fatigueDaytime fatigue Impaired concentration/memory lossImpaired concentration/memory loss Mood/behavioral changesMood/behavioral changes Morning headachesMorning headaches Loss of sexual interestLoss of sexual interest

31. Pearls If person is on 3 antihypertensive medications and still has high blood pressure, consider a sleep studyIf person is on 3 antihypertensive medications and still has high blood pressure, consider a sleep study When a person has “congestive heart failure” due to fluid buildup and their BNP is less than 120, screen for sleep apneaWhen a person has “congestive heart failure” due to fluid buildup and their BNP is less than 120, screen for sleep apnea Newly diagnosed CHF patients should be screened for sleep apnea earlyNewly diagnosed CHF patients should be screened for sleep apnea early Atrial fibrillation patients should be screenedAtrial fibrillation patients should be screened All cardiac patients should be screened when no other known cause for cardiac conditionAll cardiac patients should be screened when no other known cause for cardiac condition

33. Suggestions for cardiac patients to use CPAP/ BIPAP Use humidifier on CPAP to prevent drynessUse humidifier on CPAP to prevent dryness Nasal spray to open air passagesNasal spray to open air passages Wear during naps to get used to mask and get a boost of energy for rest of the dayWear during naps to get used to mask and get a boost of energy for rest of the day Encourage support from spouse/SOEncourage support from spouse/SO Give CPAP a friendly nameGive CPAP a friendly name Use at least 4 hours per night for benefitUse at least 4 hours per night for benefit

34. Great News Treatment can give people a new lease on lifeTreatment can give people a new lease on life More energyMore energy Relieve headachesRelieve headaches Control blood pressureControl blood pressure Sleep all nightSleep all night Less strain on the heartLess strain on the heart Reduces cardiac eventsReduces cardiac events Improve CHF symptomsImprove CHF symptoms

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36. Sleep tight