Sleep Apnea and Congestive Heart Failure, Diagnosis and Management. Rami Kahwash, MD

Transcription

1 Sleep Apnea and Congestive Heart Failure, Diagnosis and Management Rami Kahwash, MD Orlando, Florida October 7-9, 2011

2 Presentation Outline Overview of sleep disordered-breathing (SDB) Pathophysiology of the cardiovascular consequences of OSA and CSA Treatment of OSA-Focus on the cardiovascular impact of treatment Treatment of CSA

3 Case History 61 y/o commercial driver presents to the clinic with: Excessive daytime sleepiness Snoring and pauses in breathing reported by the wife Difficult to concentrate on the job!

4 Sleep History Seven and half hours of allowed sleep per night Tired in the morning Awakens 3-4 times at night to use rest room Persistent loud snoring Leg jerks and kicks- restless sleep

5 Case History MHX: Hypertension Hypercholesterolemia ROS: 35 lbs weight gain/past two year SoHx: 40 Pack/year

6 NEXT STEP POLYSYMNOGHRAPHY

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8 EKG Airflow Thoracic effort Abd. effort SAO2

9 EKG Exhale Airway obstructs Airway opens Airflow Effort gradually increases Thoracic effort Abd. effort SAO2 Paradoxing Blood oxygen levels reduce to < 4% of baseline value Paradoxing Ends Obstructive Apnea: partial or complete cessation of upper airway despite continued efforts to breath

10 ECG ECG Airflow Airflow Thor. Thor. Effort Effort Abd. Abd. Effort Effort SAO SAO 2 2 Central sleep apnea: cessation of upper airway flow without respiratory effort.

11 Sleep Medicine Nomenclatures Apnea: complete cessation of airflow > 10 seconds Hypoapnea: decrease in airflow > 30 %, longer than 10 sec, associated with decrease in O2 sat > 4 % or arousal AHI: number of events per hour 5-15Mild moderate >30 severe

12 Prevalence of Obstructive Sleep Apnea The Wisconsin Sleep Cohort, NEJM 1993 The Occurrence of Sleep-Disordered Breathing among random 602 Middle-Aged Adults.

13 Prevalence in Middle Aged Adults % Men % Women AHI 5 AHI 5 + daytime somnolence AHI = Apnea Hypopnea Index Young; NEJM 1993

14 Prevalence of OSA in Stable Outpatients with Heart Failure

15 Physical Examination in OSA Malampati Class (I-IV) Obesity and thick neck > 17 inch males > 16 inch females Craniofacial anatomy Inferiorly positioned hyoid bone Mandibular insufficiency Increased mid-facial height Nasal obstruction

16 Mallampati Class: Independent Predictor of the Presence and Severity of OSA Nuckton et al, Sleep 2006 Mallampati class

17 SCHELLENBERG et al AJRCCM 2000

18 SCHELLENBERG et al AJRCCM 2000

19 Cardiovascular Consequences- Pathophysiology Caples,et al.,sleep,vol. 30, No.3,2007

20 OSA AND Hypertension 40% of patients with OSA have hypertension 50% of patients with hypertension have OSA OSA patients are more likely to be nocturnal non-dippers Treatment of OSA reduces blood pressure

21 OSA- Induced Hypertension-Animal Model Brooks, et al. J Clin Invest 99:106, 1997

22 OSA and CHF-the Sleep Heart Health n=6,424 E Shahar, et al, AJRCCM, 2001

23 SBD and Heart Failure in Clinical Practice Congestive heart failure CS A OSA Diastolic dysfunctio n Coronary disease or hypertension Systolic dysfunction OSA

24 Weight loss Positive airway pressure Surgery Oral appliances Oxygen Treatment of OSA

25 Respiratory Effects: Effects of CPAP Elimination of upper airway obstruction Unloading of respiratory muscles Improved work of breathing Improved gas exchange and elimination of desatruration

26 Causative Role of Severe Untreated OSA in Cardiovascular Events mean F/u 10 YR (Marin et al, Lancet 365:1046, 2005)

27 CPAP Improves LVEF in Patients with CHF CPAP group had a significant absolute increase of 8.8±1.6 percent in the left ventricular ejection fraction (P<0.001) Kaneko et al, NEJM 348:1233, 2003

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29 Management of CHF Supplemental Oxygen Acetazolamide Theophylline Pacemaker Heart Transplantation CSA : Treatment

30 CANPAP 258 patients age with heart failure, ejection fraction < 40%, and central sleep apnea despite optimal medical therapy Randomized. Mean age 63 years. Baseline ejection fraction 24.5% Nocturnal CPAP Titrated as tolerated to 10 cmh 2 O n=128 No CPAP n=130 Endpoints (mean follow-up 2 years): Primary: Death or heart transplantation Secondary: Apnea hypopnea index, quality of life CPAP was used an average of 4 hours per day during the trial Bradley TD et al. N Engl J Med 2005; 353:

31 CANPAP Primary Endpoint: Death or hospitalization p= nocturnal CPAP no CPAP Average sleep time was 304 minutes in the CPAP group and 308 minutes in the control group. Apnea hypopnea index at baseline was 40 apneas/hour There was no difference in the frequency of death or hospitalization between groups or in the cumulative number of hospitalizations (p=0.83)

32 SDB and Cardiovascular Diseases- Conclusions OSA has a causative relation with hypertension OSA is a independent risk factor for: Heart failure CAD Stroke Cardiac arrhythmia OSA causes worse outcomes in stroke, CAD, and Afib. Main therapy is CPAP. CSA coexist with heart failure and aggravate its control. Main therapy is optimizing HF control

33 Thank You