Transcript Obstructive Sleep Apnea and Heart Disease

Obstructive Sleep Apnea and
Heart Disease
Cardiology Cath Conference
3/31/11
Andrew Binder
Overview
• Prevalence and Definition
• General hemodynamic effects
• OSA and specific cardiovascular effects
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HTN
Heart Failure
Atherosclerosis and Inflammation
Arrhythmias
Pulmonary Hypertension
• Treatment of OSA
Obstructive Sleep Apnea
• Affects 15 million adult Americans
• Repetitive collapse of the pharynx that triggers
apneas during sleep
– Intermittent hypoxia
– Exaggerated negative intrathoracic pressures
– Surges in sympathetic nervous system activity
– Increased blood pressure
– Frequent awakenings
Kasai et al. JACC 2011
Pathogenesis of OSA
• OSA patients usually have a
narrow pharynx
• At sleep onset there is loss
of pharyngeal dilator
muscle tone which causes
complete or partial
pharyngeal collapse causing
obstructive apneas and
hypopneas.
Kasai et al. JACC 2011
Screening for OSA
• Epworth Sleepiness Scale
• Berlin questionnaire
• Overnight oximetry – most often used in clinical
practice
Spaak J et al. Hypertension 2005
Definition
• Apnea - > 90% reduction in tidal volume lasted >
10 seconds
• Hypopnea – reduction in tidal volume of 50 – 90%,
lasted > 10 seconds accompanied by > 3% decrease
in oxygen saturation or terminated by arousal from
sleep
• AHI – apnea-hypopnea index > 5 = OSA disorder
Kasai et al. JACC 2011
Diagnosis of OSA
• OSA syndrome
– > 5 episodes of apnea or hypopnea per hour of sleep
– Hypersomnolence
– Episodes of choking or gasping during sleep
– Recurrent awakenings
– Unrefreshing sleep
– Daytime fatigue
– Impaired concentration or memory
Kasai et al. JACC 2011
OSA
Sleep Disordered Breathing- “The
basic definition”
Obstructive Sleep Apnea
Central Sleep Apnea
Idiopathic Central Sleep Apnea
Syndrome
Cheyne-Stokes
Respiration
Mechanisms of Disease
Spaak J et al. Hypertension 2005
Prevalence of OSA in Stable
Outpatients with Heart Failure
60%
57%
50%
Prevalence
40%
30%
57%
57%
43%
20%
43%
48%
36%
30%
10%
0%
57%
Oldenburg 2007
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Schulz 2007
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Khayat 2009
Macdonalad
2008 Paulino
2009
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7
Bitter 2009
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Prevalence of OSA in HF
Kasai et al. JACC 2011
Risk Factors for OSA
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Age: females after menopause
Obesity: particularly males and middle aged women
Neck circumference
Craniofacial predisposition and family history
Certain racial groups
Cardiovascular disease and heart failure
Symptoms of OSA
• Snoring
• Excessive daytime sleepiness
• Witnessed apneas
• Poor memory and concentration, irritability or
personality changes
• Other: Dry throat, morning headache, and nocturia
Physical Examination in OSA
• Malampati Class
• Obesity and thick neck
– > 17 inch males
– > 16 inch females
• Craniofacial anatomy
– Inferiorly positioned hyoid bone
– Mandibular insufficiency
– Increased mid-facial height
• Nasal obstruction
Upper Airway in OSA
Normal
Patient
Normal Individual
Obese Patient
Sleep – Cardiovascular Quiescence
• Normally, during non-REM sleep:
– Decrease in metabolic rate, sympathetic nervous system
activity (SNA), blood pressure (BP), and heart rate (HR)
– Increase in cardiac vagal activity
• Disrupted by OSA
• HF patients sleep approximately 1.3 hours less than
subjects without HF
C
Kasai et al. JACC 2011
Effects of OSA
Spaak J et al. Hypertension 2005
OSA
• OSA has been independently linked to multiple
cardiovascular outcomes
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HTN
CVA
Myocardial Ischemia
Arrhythmias
Fatal and nonfatal cardiovascular events
All cause mortality
• Treatment of OSA may represent a novel target to
reduce cardiovascular health outcomes.
Selim et al. Clim Chest Med 2010
Hypertension
• 50% of OSA patients are hypertensive
• 30% of hypertensive patients also have OSA, often
undiagnosed
• Non-dippers
• Logan et al found the prevalence of OSA in resistant
hypertension to be 83%
Logan et al. J Hypertension 2001
Hypertension
Peppard PE et al. NEJM 2000
Hypertension
• Multiple studies with conflicting results of effect of
treatment of OSA on hypertension
• 3 recent meta-analyses shown significant but modest
reduction in BP (~ 2 mm Hg).
• Patient with more severe OSA, difficult to control
hypertension, and better CPAP compliance had
more substantial BP reduction with CPAP.
Haentjens P et al. Arch Intern Med 2007
Bazzano et al Hypertension 2007
Alajmi et al Lung 2007
Heart Failure
• 11% - 37% of patients with systolic dysfunction had OSA
detected on polysomnography
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– Very few complained of excessive daytime sleepiness
Men > Women (38% vs. 31%)
Major risk factor in men: obesity
Major risk factor in women: older age
Prospective study where polysomnography was performed on
all consenting patients newly referred to a tertiary hospital
heart failure clinic
– 26% had OSA with an AHI > 15
– OSA noted in > 50% of HFPEF
Spaak J et al. Hypertension 2005
OSA and Heart Failure
• Most direct mechanism in which OSA can induced
LV dysfunction is by raising BP.
• Also:
– Increased sympathetic outflow
– Increased LV afterload acutely and chronically
– Hypoxia induced increase of RV afterload
– Increased risk of myocardial infarction
Spaak J et al. Hypertension 2005
OSA and Heart Failure
• OSA
Yumino et al. Circulation 2010
Heart Failure
Heart Failure
Spaak J et al. Hypertension 2005, Usui K et al.
JACC 2005
Kaplan–Meier survival curves of death from any cause in patients with (A) ischemic heart
failure (HF) and (B) non-ischemic HF.
Yumino D et al. Heart 2009;95:819-824
©2009 by BMJ Publishing Group Ltd and British Cardiovascular Society
ICD therapy and SDB
Serizawa N et al. Am J Cardiol 2008
Day-Night pattern of ICD therapy
Serizawa N et al. Am J Cardiol 2008
Effect of OSA treatment on HF
Spaak J et al. Hypertension 2005
Atherosclerosis
Savransky et al. Am J Respir Crit Care Med
2007
Endothelial Effects
• Oxidative stress  reactive oxygen species  inflammation
Minoguchi et al. Am J Respir Crit Care Med
2005
CIMT and OSA
Drager et al. Am J Respir Crit Care Med 2005
Treatment of OSA and CIMT
Drager et al. Am J Respir Crit Care Med 2007
CPAP and inflammation
Yokoe et al. Circulation 2003
Myocardial Ischemia
• Prevalence of SDB in CAD patients is up to 2-fold
greater than in non-CAD subjects.
Spaak J et al. Hypertension 2005
Myocardial Ischemia and Infarction
• Ischemia
• CAD
– Severe intermittent
hypoxemia
– Acidosis
– Increased BP
– Sympathetic
vasoconstriction
– Changes in intra thoracic
and cardiac trans mural
pressures
– Endothelial dysfunction
– Systemic inflammation
Spaak J et al. Hypertension 2005
Multivariate analysis for the association between OSA severity measured by AHI quartile and
CAC.
Sorajja D et al. Chest 2008;133:927-933
©2008 by American College of Chest Physicians
Sudden Cardiac Death in OSA
N Engl J Med 2005;352:1206-14.
Arrhythmias
• Nocturnal arrhythmias have been shown to occur in
up to 50% of OSA patients.
– Nonsustainted ventricular tachycardia
– Sinus arrest
– Second degree AV block
– Frequent PVC’s
Franz et al. Circulation 1992
Aviles et al. Circulation 2003
Arrhythmias and OSA
Mehra R et al. Am J Respir Crit Care Med 2006
Brady arrhythmias
• Apnea and hypoxemia in OSA can elicit the diving
reflex resulting in cardiac vagal activation
• AV blocks or asystole may develop, even in the
absence of cardiac conduction disease.
• 59% of patients with pacemakers have sleep apnea
Garrigue et al. Circulation 2007
Pulmonary Hypertension
• 16% - 42% of patients with OSA have PH
• PH in OSA patients is associated with:
– Obesity
– Poor lung function
– Degree and duration of hypoxemia
– Hypercapnea
– Not associated with age, gender or OSA severity
• Typically mean PAP is only mildly elevated unless
there is underlying lung or heart disease.
Chaouat A et al. Chest 1996
Selim et al. Clin Chest Med 2010
Pulmonary Hypertension
• Hypoxemia-induced pulmonary vasoconstriction
leads to vascular remodeling
• Large negative intrathoracic pressures generated
during obstructive apneas
– increase LV transmural pressure causing greater
myocardial oxygen demand, reduced CO, and increased
wedge pressure.
– Increase wall stiffness of large vessels and increase
impedance
Spaak J et al. Hypertension 2005
Pulmonary Hypertension
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Randomized, cross-over trial
23 middle-aged OSA and otherwise healthy patients
10 control subjects
Measured PA pressure by TTE
Arias et al. Eur Heart Journal 2006
Individual values for the PASP in OSA patients and control subjects.
Arias M A et al. Eur Heart J 2006;27:1106-1113
© The European Society of Cardiology 2006. All rights reserved. For Permissions, please e-mail:
[email protected]
Individual values for the PASP after both sham and effective CPAP treatment in OSA patients.
Arias M A et al. Eur Heart J 2006;27:1106-1113
© The European Society of Cardiology 2006. All rights reserved. For Permissions, please e-mail:
[email protected]
Treatment of OSA
• Obesity is single most important cause of OSA
• Weight loss leads to
– Decrease in AHI
– Improved sleep efficiency
– Decreased snoring
– Improved oxygenation
• Positional apnea
Treatment of OSA
• CPAP
– Proper introduction and education
– Proper humidification
– Careful selection of appropriate mask
– Pressure ramp
– Bilevel or autotitrating device
• Oral appliances
• Surgery
Conclusion
• OSA is prevalent
• Multiple adverse cardiovascular consequences