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Does Treating Sleep Apnea Help the Heart? Updates in Cardiology 2017 March 4, 2017
David B. Min, MD Intermountain Heart Institute
Disclosures: David B. Min, MD - None
Learning Objectives • Recognize the relationships between sleep apnea and
cardiovascular disease • Cognizant of ongoing research examining the effects of treating
sleep apnea and heart disease • Familiarity of sleep apnea treatment options in patients with
cardiovascular disease
What is Sleep Disordered Breathing? Repetitive cessation or near cessation of breathing during sleep • Desaturation • Arousal
Obstructive Sleep Apnea • Pharyngeal airway obstruction
Central Sleep Apnea • Interruption of central drive to breathe
Mixed Sleep Apnea
Mechanisms of Obstructive Sleep Apnea
Decreased distal airway traction - supine posture - small lung volumes
Loss of static pharyngeal dilator tone during REM sleep -genioglossus and tensor pallatini -?? leptin, ghrelin, IL-6, TNF-α
Proximal airflow resistance - mandible length - tongue volume - hyoid position - adiposity
Oral appliances Surgery Weight loss Supplemental O2
Positive Airway Pressure • CPAP/BiPAP • Adaptive servo-ventilation (ASV)
Hypoglossal nerve stimulation
OSA and Heart Disease 2016
Treatment of Sleep-Disordered Breathing
Ref: Strollo PJ et al. N Engl J Med 2014; 370:139.
Sleep Apnea & Cardiovascular Disease
Ref: Javaheri, S. et al. J Am Coll Cardiol. 2017;69(7):841–58.
Prevalence of Sleep Apnea & Cardiovascular Disease HTN 30%
OSA
CAD 40%
ESRD 60%
CVA/TIA
60%
CHF 40%
Arrhythmia
60%
Ref: Cepeda-Valery B et al. Curr Cardiol Rep 2014; 16: 535.
Fatal MI or stroke Non-fatal MI or stroke or need for revascularization
Ref: Marin JM et al. Lancet 2005; 365: 1046-54.
Cardiac Event Risk in Severe OSA
All OSA Mild-moderate OSA
p < 0.001 p < 0.001
Ref: Buchner NJ, et al. Am J Respir Crit Care Med 2007; 176: 1274.
p=0.009 p=0.024
CPAP Therapy & Cardiac Event Risk in Mild-Moderate OSA
Ref: Barbé F et al. JAMA 2012; 307: 2161.
CPAP Therapy & Cardiac Events: RCT Data
Sleep-Disordered Breathing & Specific Cardiac Conditions
Coronary Artery Disease & OSA
Severe OSA increases risk for ischemic events • Independent of co-morbidities OSA carries increased risk for incident CAD • Independent of co-morbidities OSA is associated with poorer CAD outcomes • Medical therapy • Revascularization Impact of CPAP therapy on CAD outcomes
OSA and Heart Disease 2016
OSA & STEMI Survival 120 STEMI patients • 105 sleep studies • No OSA treatment
OSA prevalence • Severe: 42% • Non-severe: 58%
Combined endpoint • Death, repeat MI, stroke, unplanned TVR, CHF admission
p=0.049
Ref: Lee CH et al. J Clin Sleep Med 2011; 7 (6): 616. OSA and Heart Disease 2016
Baseline Post treatment
Ref: Pepperell JC et al. Lancet 2002; 359:204. OSA and Heart Disease 2016
Hypertension: CPAP Effect – RCT
Hypertension: CPAP Affect – Resistant HTN
Ref: Javaheri, S. et al. J Am Coll Cardiol. 2017;69(7):841–58.
Sleep-Disordered Breathing & Heart Failure OSA & Heart Failure CSA & Heart Failure
Ref: Parati, G. et al. Nat Rev Cardiol. 2016;13:389-403.
Augmented hyperadrenergic state in OSA & CSA
Ref: Wang H et al. J Am Coll Cardiol 2007; 49: 1625. OSA and Heart Disease 2016
OSA & Heart Failure Survival
CPAP & Heart Failure Survival - CSA
Ref: Bradley TD et al. N Engl J Med 2005; 353: 2025. OSA and Heart Disease 2016
ASV & Heart Failure Survival - CSA
Ref: Cowie M et al. N Engl J Med 2015; 373: 1095. OSA and Heart Disease 2016
? Increase PAP decreases cardiac output ? CSA is a compensatory mechanism for HFrEF ? Older generation ASV excessive ventilation
Sleep-Disordered Breathing & Heart Failure - Summary Severe OSA increases risk for heart failure in men OSA and CSA are both prevalent in heart failure populations Untreated severe OSA decreases heart failure survival Impact of CPAP on heart failure mortality unclear • CSA: CPAP – no improvement. ASV – contraindicated. • OSA: CPAP improves hemodynamics. Impact of heart failure therapy on OSA unclear
OSA and Heart Disease 2016
Sleep-disordered breathing is highly prevalent in patients with cardiovascular diseases • Associated with substantial morbidity
CPAP therapy improves quality of life in symptomatic OSA Research on CPAP on cardiac outcomes is ongoing
OSA and Heart Disease 2016
SUMMARY