Obstructive Sleep Apnea Risk Factor and Complication of Stroke

Transcription

1 Obstructive Sleep Apnea Risk Factor and Complication of Stroke 10 th Annual Cerebrovascular Symposium May 5, 2016 Sandeep P Khot MD Associate Professor of Neurology University of Washington School of Medicine Harborview Medical Center Seattle, Washington 1

2 FINANCIAL DISCLOSURE: Research Grant Support: UW Institute of Translational Health Sciences Small Pilot Grant; American Sleep Medicine Foundation Focused Projects Award Material Support: Philips Respironics CPAP machine donations for research study 2

3 OSA as Risk Factor for Stroke Obstructive sleep apnea (OSA) common, under-recognized stroke risk factor, with estimated prevalence 50-70% OSA 30% more common in stroke patients; moderate-severe OSA in men with 3-fold higher risk of stroke Estimated 6% increased stroke risk per unit increase in AHI Herman DM. Neurology 2009 Bassetti CL. Stroke 2006 Shahar E. Am J Respir Crit Care Med

4 OSA as Risk Factor for Stroke HR 1.97 ( ; p=0.01) Yaggi HK. NEJM 2005; Munoz R. Stroke

5 Yaggi H. Lancet Neurol

6 Johnson KG. J Clin Sleep Med

7 Chicken: - No link between stroke severity, topography or presumed etiology - Frequency of OSA similar with TIA and stroke Egg: - OSA improves in subacute stroke phase - -CSA, C-S respiration and positional SA improve with time (more so than OSA) Hermann DM. Neurology

8 CPAP Treatment after Stroke Martinez-Garcia MA. Eur Resp J For non-fatal cardiovascular events: HR 2.87 (CI ), p=0.03 Adjusted for age, sex, BI, other cardiovascular risk factors For fatal cardiovascular events: HR 1.76 (CI ), p=0.009 NNT=4.9 patients 8

9 CPAP Treatment after Stroke 50/57 vs 61/69, p=0.91 Parra O. Eur Resp J

10 AHA Guidelines Kernan W. Stroke

11 STOP-BANG Questionnaire 1. Snoring: do you snore loudly (loud enough to be heard through closed doors)? 2. Tired: do you often feel tired, fatigued, or sleepy during daytime? 3. Observed: has anyone observed you stop breathing during your sleep? 4. Blood pressure: do you have or are you being treated for high blood pressure? 5. BMI: BMI more than 35 kg/m2? 6. Age: age more than 50 years old? 7. Neck circumference: neck circumference greater than 40 cm? 8. Gender: male? High risk of OSA: answering yes to 3 or more items. Low risk of OSA: answering yes to fewer than 3 items. Chung F. Anesthesiology

12 Atherosclerosis Hypercoagulability Cerebral hemodynamics Sympathetic activation OSA Stroke 50-70% Neuronal Plasticity Ischemic Penumbra Excessive Daytime Sleepiness Stroke Functional Outcome OSA predicts stroke outcome Johnson KG. J Clin Sleep Med 2010 Bassetti CL. Stroke 2006 Brown DL. Semin Neurol 2006 Kaneko Y. Sleep

13 OSA as Predictor of Stroke Outcome OSA may adversely affect recovery from stroke in short-term and long-term Stroke patients with OSA do not have same degree of sleepiness as non-stroke patients and have lower BMI values Currently no guidelines on who, when or how to best screen stroke patients for OSA Selic C. Stroke 2005; Kaneko Y. Sleep 2003 Sahlin C. Arch Intern Med 2008; Arzt M Am J Respir Crit Care

14 OSA as Predictor of Stroke Outcome Mean 44.6 (+/- 3.1 days) from stroke onset to PSG Multiple regression analysis: OSA significantly, independently related to functional impairment and length of hospitalization Kaneko Y. Sleep

15 Tomfohr LM. Stroke

16 CPAP after Acute Stroke Ryan C. Stroke

17 CPAP after Acute Stroke Ryan C. Stroke

18 CPAP after Acute Stroke Auto-titrating CPAP for 3 nights from 1 st night after stroke and continued for 4 more nights if AHI > 10 Minnerup J. Stroke

19 CPAP after Acute Stroke 21/31 within 2 days 13/15 (87%) AHI 5 24/35 (69%) AHI 5 13/15 (87%) AHI 5 Bravata D. Sleep

20 CPAP after Acute Stroke Khot S. J Clin Sleep Med (in press) 20

21 On-treatment FIM Change, n=30 P=0.11 P=0.17 P=0.06 Khot S. J Clin Sleep Med (in press) 21

22 Lesser of two evils Up to 30% prescribed CPAP refuse from onset and 25% remaining discontinue within 1 year Only 50% of non-stroke patients remain adherent long-term (4 hrs use on 70% nights-- 21/30 days) Long-term adherence determined after 3 nights of use Poor treatment adherence (12% and 15% in 2 studies) is major limitation among stroke patients due to poor CPAP tolerance Wickwire EM. Chest 2013; Stepnowsky CJ. Sleep Med. 2002; Hui DS. Chest 2002; Bassetti CL. Stroke

23 Patterns of CPAP adherence Established early (1 st night) and predict long-term use Subjective and objective monitoring CPAP has been shown to be discordant Social variables, including social support and partner s sleep quality affect decision to adhere Disease severity less important than symptom relief Dose response relationship between hours of use and both health related and functional outcomes Lewis K. Sleep 2004; Kribbs N. Am Rev Respir Dis 1993; McCardle N Thorax

24 Weaver T. Proc Am Thorac Soc

25 SCOUTS 2 Aims Enroll stroke patients admitted for inpatient rehabilitation into pilot, clinical trial to identify means to maximize CPAP tolerance and adherence during inpatient rehabilitation and for a 3-month period from enrollment Assess relationship between CPAP adherence and neurological recovery using the change in the Functional Independence Measure (FIM) at discharge and at 3 months following enrollment 25

26 Phase 1 Phase 2 Phase 3 Phase 4 90 pts Enrollment: ischemic stroke or intraparenchymal hemorrhage patients admitted to inpatient rehabilitation unit (day 0)* *All patients referred to sleep medicine clinic after discharge Active autotitrating CPAP Run-in period (nights 1-3) 3 nights of Auto-CPAP & intensive CPAP adherence protocol 80% + vs 20% - 54 pts (~75%) Screen Positive & willing to continue CPAP (day 4)ǂ Screen Positive & unwilling to continue CPAP (day 4) ǂ 18 pts (~25%) 40 pts (~75%) CPAP at d/c 27 (~50%) 3 mo. adherent CONTINUED INTERVENTION 3 months CPAP (continued upon rehab discharge) & intensive CPAP adherence protocol Outcomes CPAP Adherence (run-in period, rehabilitation discharge & 3 months from enrollment) Functional and Neurologic Outcome (rehabilitation admission, rehabilitation discharge & 3 months from enrollment) ǂ Screen positive defined as evidence of obstructive sleep apnea: AHI > 5 OR median CPAP pressure > 6 cm H 2 O AND clear airway apnea index < 10 26

27 Thank you Questions? 27