Does sleep apnea cause heart disease?

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1 Does sleep apnea cause heart disease? Updates in Cardiology Mar 2015 Robert J Farney MD Intermountain Sleep Disorders Center LDSH Medical Director

2 Does sleep apnea cause heart disease? Why do you want to know?

3 17 year old male with hypoxemia and observed apneas post-operatively (appendectomy). Restless sleep No loud snoring Morning inertia Excessive sleep tendency Epworth Sleepiness Score 10 FH: Father (38) Issues with sleep at night Fatty Liver Myocardial Infarction Wt 236 lb Ht 67 BMI 36 kg/m 2 BP 149/79

4 17 year old male with hypoxemia and observed apneas post-operatively (appendectomy). AHI 9.5/hr (4%) ODI 14/hr

5 Does sleep apnea cause heart disease? Why do you want to know? Does sleep apnea worsen heart disease? Does therapy of sleep apnea prevent or ameliorate heart disease?

6 Cardiovascular Mortality in OSA in the Elderly: Role of Long-Term CPAP Treatment. Prospective Observational Study. M Martinez-Garcia Am J Respir Crit Care Med 2012;186(9): A AHI 30/h AHI 5 to <30/h OSA with CPAP Control AHI < 15/h

7 Strong associations between OSA and cardiovascular disease. 1. Cardiovascular Mortality 2. Nocturnal Sudden Death 3. Hypertension 4. Atrial Fibrillation 5. Conduction Disorders 6. Coronary Artery Disease *Despite confounding factors including age, sex and obesity, but mainly true before the age of 70.

8 Strong associations between OSA and cardiovascular disease. 1. Cardiovascular Mortality 2. Nocturnal Sudden Death 3. Hypertension 4. Atrial Fibrillation 5. Conduction Disorders 6. Coronary Artery Disease *Despite confounding factors including age, sex and obesity, but mainly true before the age of 70.

9 Basic mechanisms linking OSA and cardiovascular disease. 1. Sleep state fragmentation 2. Marked intrathoracic pressure swings 3. Sympathetic nervous system overactivity 2. Intermittent hypoxemia

10 Basic mechanisms linking OSA and cardiovascular disease. 1. Sleep state fragmentation 2. Marked intrathoracic pressure swings 3. Sympathetic nervous system overactivity 2. Intermittent hypoxemia

11 EEG Microawakenings OBSTRUCTIVE SLEEP APNEA EOG No Airflow Thoracic effort Leg Jerks Hypoxia 5 Minutes

12 EEG Micro-awakenings Micro-awakenings EOG No Airflow Thoracic effort Leg Jerks Leg Jerks Hypoxia 5 Minutes

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19 Eur Respir J 2014;44: DOI: / % oxygen desaturation index (ODI) but not the AHI was independently associated with hypertension. Odds ratios (95%) ODI 2.01 ( AHI 0.92 (0.74-1/15)

20 J Clin Sleep Med 2014;10(8): patients with moderate to severe sleep apnea and CV risk factors recruited from cardiology practices participating in a multi-site randomized controlled study. Controlled BP 61.6% Uncontrolled elevated BP 28.5% Resistant elevated BP 9.9%

21 J Clin Sleep Med 2014;10(8): Participants with severe OSA (AHI 30/hr) had a 4-fold higher adjusted odds of resistant elevated BP.

22 JAMA 2013;310(22): doi: /jama

23 2013;144(5): Treatment of OSA with CPAP significantly reduces daytime BP in patients with resistant hypertension. Study designed to investigate patients with true resistant hypertension, compliant with both medications and CPAP.

24 CHEST 2003;124:

25 Effects of Obstructive Sleep Apnoea on Heart Rhythm V Rossi Eur Respir J 2013;41: Conduction Disturbances 2.Atrial Arrhythmias 3.Ventricular Arrhythmias 1.Ventricular Repolarization Disturbances

26 Effects of Obstructive Sleep Apnoea on Heart Rhythm V Rossi Eur Respir J 2013;41: Conduction Disturbances 2.Atrial Arrhythmias 1.Ventricular Arrhythmias 1.Ventricular Repolarization Disturbances

27 Heart rate response to hypoxemia depends on circumstances

28 Bradycardia during Sleep Apnea. Characteristics and Mechanism. Zwillich J Clin Invest 1982; 69:

29 59 year old female with nocturnal hypoxemia I wake up feeling like I can t breathe. Gasping for air and usually lose bladder control. Can t go back to sleep. During the day, I fall asleep wherever I am, church, bus stop, library etc. No known history of snoring or witnessed apneas. Sleeps in a chair due to PND. No smoking for > 30 years. No cough or sputum but has chest tightness. PMH: Diabetes, Hypertension, Neuropathy, Back Pain. MEDs: Neurontin, Diovan, Glucotrol, Azmacort, Albuterol, Celebrex, Ultram ( sparingly ) 214 lbs, 65 BMI 36 Decreased breath sounds. Mild edema.

30 59 year old female with nocturnal hypoxemia

31 59 year old female with nocturnal hypoxemia

32 Prevalence of Nocturnal Atrial Fibrillation in patients with OSA compared to normals 3-5% vs 0.4-1% 1. R Mehra. Am J Respir Crit Care Med 2006;173: C Guilleminault. Am J Cardiol 1983;52: H Abe Heart Vessels 2010;25:63-69.

33 Association of Nocturnal Arrhythmias with Sleepdisordered Breathing. The Sleep Heart Health Study. R Mehra Am J Respir Crit Care Med 2006;173: ATRIAL FIBRILLATION OSA vs Control (AHI 30 vs < 5) ODDS RATIO (95% CI) Unadjusted 5.66 ( ) Age, Sex, BMI 3.85 ( ) Age, Sex, BMI, CHD 4.02 ( )

34 Prevalence of Atrial Fibrillation in patients with OSA ± Comorbidity OSA- OSA CAD CHF HCM* 1. T. Mooe Coron Artery Dis 1996;7: S Javaheri Circulation 1998;97: RP Pedrosa Chest 2010;137: *Hypertrophic cardiomyopathy

35 Association of Atrial Fibrillation and Obstructive Sleep Apnea. AS Gami Circulation 2004;110:

36 Obstructive Sleep Apnea and the recurrence of AF. R Kanagala Circulation 2003;107: Recurrence of AF at 12 months post cardioversion 82% 53% 42% Control (79) CPAP Rx (12) No Rx (27) BMI (kg/m 2 ) NYHA I (%) AHI (events/hr)

37 Take Home Key Findings: 1. Sleep apnea worsens cardiac function and increases other cardiovascular risk factors. 2. Despite numerous limitations, various definitions and confounding variables, sleep apnea is a primary cause of heart disease. 3. Therapy of sleep apnea, usually with positive airway pressure, reduces morbidity and mortality due to cardiovascular disease.

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