Impact of Untreated OSA

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2 Impact of Untreated OSA Motor vehicle crashes are the leading cause of morbidity and mortality In the US more than 40,000 deaths and 6 million injuries every year Sleep-related accidents comprise 15-20% of motor vehicle crashes

3 Sleep Disordered Breathing: Definition Obstructive Sleep Apnea (OSA) Sleep related blockage or collapse of upper airway leading to absence of airflow associated with rib cage and abdominal excursions Central Sleep Apnea (CSA) Sleep related cessation of breathing due to reduced neural output from central nervous system respiratory control centers

4 Obstructive Sleep Apnea Cessation of Airflow Increasing Respiratory Efforts

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6 Sleep Apnea Wakefulness Sleep Airway Patency Compensation Decreased Compensation Hyperventilation O 2 & CO 2 Arousal Sleep Airway Collapse O 2 & CO 2 Increased Effort to Breathe

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

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

9 Prevalence of Sleep Disordered Breathing in Cardiovascular Disease 30% of hypertensive patients 83% of refractory hypertension Logan et al, J Hypertension % of heart failure patients Javaheri, Circulation % pts with systolic HF 50% pts with diastolic HF 30% of cardiac disease patients Schafer et al, Cardiology 1999

10 Association Between OSA & Hypertension 40-60% 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, 6 Patients 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 5 ¹Silverberg, et al., Curr Hypertens R Kraicze, et al., AJRCCM Bixler, et al., Arch Intern Med Logan, et al., J Hypertens Heinrich, et al., Circulation Neito, et al., Jama 2000

11 New England Journal of Medicine, 2000 Peppard et al

12 Association Between OSA & Heart Failure 37% of 450 HF patients had OSA Also high incidence of Central or Mixed apneas Risk 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:

13 Cardiovascular mortality and morbidity in OSA Marin, et al LANCET 2005 Study 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 measured Study Fatal and Non-Fatal Cardiac Events Marin, JM et. al Lancet 2005: 365:

14 Fatal CV Events over 10 year period Marin, JM et. al Lancet 2005: 365:

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

16 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 years Risk factor: 2.87 higher than norms Patients 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:

17 Treatment of OSA with CPAP 60 patients with moderate to severe OSA randomized to receive therapeutic or subtherapeutic CPAP for 9 weeks 16 patients in each group completed the study An equal amount of patients (14) dropped out of either group for similar reasons Patients were dropped from study if their medications changed A total of 15 patients were on anti-hypertensive meds 8 were on 2 or more meds Therapeutic CPAP titrated to reduce AHIs by 95% average pressure 9 cm H 2 0 average compliance 5.5 hrs Sub-therapeutic group received 3-4 cm H 2 0 sham CPAP average compliance 5.4 hrs Becker FH., et al., Circulation 2002; 107: 68-73

18 Results: CPAP 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 CPAP

19 Treatment of OSA & Refractory HTN 16 of 19 refractory HTN patients had underlying OSA 11 patients participated in CPAP trial CPAP titrated to approx. 9 cm H 2 0 Blood pressure and baroreflex sensitivity were studied on and off CPAP 24-hour blood pressure was evaluated at baseline and after 2 months of CPAP therapy

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

21 Result: Treatment of OSA & Refractory HTN After 2 months Chronic CPAP Baseline Chronic CPAP p value 24 hour BP sys (mmhg) ± ±3.8 <0.05 Daytime BP sys (mmhg) ± ±3.7 <0.05 Night-time BP sys (mmhg) ± ±4.5 < hour BP dias (mmhg) 88.3 ± ±3.2 <0.05 Night-time BP dias (mmhg) 80.8 ± ±2.5 <0.02 Logan AG., et al., Eur Respir J 2003; 21:

22 Treatment of OSA and Benefit Atrial Fibrillation Study included 488 patients from Cardiac Clinic Untreated OSA doubled the risk of recurrence of atrial fibrillation Authors suggest patients with AF should be screened for OSA Gami et al., Circulation 2004;110:

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

25 Standard Questions to Ask All Patients? Do you snore? Have you been told you quit breathing or pause your breathing during sleep? Do you awake from sleep choking, snorting or gasping for breath? Take into consideration HTN, BMI If needed, ask about