All OSA Patients Should Not Be Treated
Patrick J. Strollo, Jr., M.D., FCCP, D,ABSMUniversity of Pittsburgh Medical Center
Turkish Thoracic Society9th Annual Congress
All OSA Patients Should Not Be Treated
• Define Obstructive Sleep Apnea
• What is the impact of treatment?
• Who benefits from treatment?
• What are the barriers?
Sleep Apnea is Associated with Significant Co-morbidities
Cardiovascular Complications
MetabolicComplications
Neuro-cognitiveComplications
Obstructive Sleep Disordered Breathing
• Mild: 5 – 15 events per hour• Moderate: 15 – 30 events per hour• Severe: > 30 events per hour
Level 2 Evidence Variable(s) on which the severity rating is based have been demonstrated to have a statistically significant relationship with excess morbidity in a prospective cohort study that has properly controlled for important covariates.
Sleep 199922:667-689
AASM Levels of Recommendation
AASM Classification of Evidence
All OSA Patients Should Not Be Treated
• Define Obstructive Sleep Apnea
• What is the impact of treatment?
• Who benefits from treatment?
• What are the barriers?
Current evidence that treatment impacts outcome
• CPAP is indicated for the treatment of moderate to severe OSA (Standard)
• CPAP is indicated for improving self reported sleepiness in patients with OSA (Standard)
• CPAP is recommended for the treatment of mild OSA (Option)
• CPAP is recommended for improving quality of life in patients with OSA (Option)
• CPAP is recommended as an adjunctive therapy to lower blood pressure in hypertensive patients with OSA (Option)
Sleep 200629:375-380
Effect of CPAP on Daytime Function
• Design: Double blinded, randomized, controlled trial
• Patients: CPAPther n =54, CPAPsham n=53• Outcome variables: Subjective sleepiness (ESS),
Objective sleepiness (MWT), SF-36
Lancet 1999Lancet 1999
353:2100-05353:2100-05
CPAPther 5.4 hours/nightESS: 15.5 => 7.0 *MWT: 22.5 => 32.9 * SF-36: 35.4 => 73.0 *
CPAPsham 4.6 hours/nightESS: 15.0 => 13.0 *MWT: 20.0 => 23.5 SF-36: 33.9 => 50.9 *
Results
* P < 0.001* P < 0.001
Effect CPAP on Blood Pressure
• Objective: Compare change in BP in men with OSA
• Design:: Randomized parallel trial
• Subjects: ODI 41.4 + 20• Outcome variable: Change
in mean BP at 4 weeks• Results: NCPAPther
decreased BP 2.5 mm Hg vs. NCPAPsubther 0.8 mm Hg– Effect was greater in
patients taking antihypertensive meds
Lancet 2001359:204-10
A BP fall of 3.3 mm Hg would be expected to be associatedwith a stroke risk reduction of about 20% & a coronary heartdisease event risk reduction of about 15%
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Effect of CPAP on Afib Recurrence
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Control OSA Treated OSA Untreated
Circulation 2003107:2589-94
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n = 79 n = 12 n = 27
53% 42%
82%
p = ns
p = 0.013
p = 0.009Population
Patients referred for cardioversionAge 65 + 10 yrsMale (81%)BMI 37 + 11AHI: 45 + 38 (treated) 34 + 29 (untreated)
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AIM: Observational study to compare incidence of fatal and non-fatal cardiovascular events in simple snorers, patients with untreated OSA,patients treated with CPAP, and healthy men recruited from the general population.Design: Prospective observational cohort. 264 healthy men, 377 simple snorers, 403 with untreated mild-moderate OSA (AHI 5-30), 235 with untreated severe OSA (AHI > 30), and 372 with OSA and treated with CPAP
Lancet 2005 365: 1046–53
MonthsMonths
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Conclusion: In men, severe OSA significantly increases the risk of fatal and non-fatal cardiovascular events. CPAP treatment reduces this risk.
Long-term cardiovascular outcomes in men with OSA
AHI 43.3 + 5.7
AHI 42.4 + 4.9
AHI 18.2 + 3.5
All OSA Patients Should Not Be Treated
• Define Obstructive Sleep Apnea
• What is the impact of treatment?
• Who benefits from treatment?
• What are the barriers?
Vulnerable populations
• Phenotypes– Severe apnea (AHI > 30)– Individuals < 55 years– Women?– Coexisting CV disease
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AIM: Observational study to compare incidence of fatal and non-fatal cardiovascular events in simple snorers, patients with untreated OSA,patients treated with CPAP, and healthy men recruited from the general population.Design: Prospective observational cohort. 264 healthy men, 377 simple snorers, 403 with untreated mild-moderate OSA (AHI 5-30), 235 with untreated severe OSA (AHI > 30), and 372 with OSA and treated with CPAP
Lancet 2005 365: 1046–53
MonthsMonths
.
Conclusion: In men, severe OSA significantly increases the risk of fatal and non-fatal cardiovascular events. CPAP treatment reduces this risk.
Long-term cardiovascular outcomes in men with OSA
AHI 43.3 + 5.7
AHI 42.4 + 4.9
AHI 18.2 + 3.5
Arch Intern Med 2002 162:893-900
Prevalence of an AHI > 15 by age
Impact of Gender on Survival
AHI < 5 AHI > 5
Thorax 199853:s16-19
n = 190
n = 32
n = 73
n = 59
Years
Dea
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in T
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sGender Difference in Cardiovascular Mortality
Women
Men
Source: CDC / CHS
Effect of OSA Rx on Cardiac Events
• Design: Prospective observational study (86.5 + 39 months)
• Patients:– N = 54 (53 M / 1 F)– Age 57.3 + 10.1– CAD (> 70% stenosis)
& AHI > 15• Endpoints:
– Cardiovascular death– Acute coronary artery
syndrome– Hospitalization for CHF– Coronary Artery
Revascularisation• Results:
– Treated 6/25 (24%)– Untreated 17/29 (58%)
p < 0.01
EHJ 200425:728-34
Treated n = 25
Untreated n = 29 E
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Time (months)
AHIbase 33.7 + 16.8
AHIbase 29.0 + 12.8
Cost Effectiveness of CPAP
Aims: To determine the short-term and long-term impacts of CPAP on HRQL in patients OSA.Design: Prospective longitudinal cohort study.Patients: Three hundred sixty-five patients with an AHI > 20 per hour of sleep and 358 patients with an AHI of < 20.Interventions: All patients with AHIs > 20 received CPAP therapy; those with AHIs < 20 did not. The HRQL of all study participants was measured using the SF-36 questionnaire at baseline and then at 3 and 12 months.
CHEST 2002122:1679–1685
Months of Follow-up
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Conclusions: CPAP therapy was associated with marked short-term and long-term improvements in the vitality of patients with moderate- to- severe OSA in the community. These findings suggest that CPAP therapy is effective in improving the long - term HRQL of patients with OSA.
All OSA Patients Should Not Be Treated
• Define Obstructive Sleep Apnea
• What is the impact of treatment?
• Who benefits from treatment?
• What are the barriers?
Sleep Apnea: Treatment Options
• Lifestyle– Fitness– Avoid sleep deprivation, Alcohol, Sedatives– Lateral position or Elevated HOB
• Medical – Positive Pressure via a mask
• CPAP • Bi-level pressure
• Oral appliances• Surgical
– Upper airway bypass (trach)– Upper airway reconstruction
• Phase 1 : UPPP & Genioglossal advancement• Phase 2: Maxillomandibular advancement
Medical- Positive Pressure via a mask
• CPAP• Bi-level pressure
Factors Affecting CPAP Adherence
• Snoring history.
• Apnea / hypopnea index ( > 30).
• Epworth sleepiness score ( > 10).
Prospective evaluation of CPAP use (n = 1,211)
Adherence at 5 yrs (68%): 3 month use predictive
AJRCCM 1999159:1108-14
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Apnea – Hypopnea Index
The Relationship of Self Reported Sleepiness to Sleep Apnea
n = 4653
Non-Sleepy Sleep Apnea
Sleepy Sleep Apnea
Obesity
Sleep Apnea Diabetes
LV Hypertrophy
Pleiotrophic Effects of Adiopkines on Vascular Risk
Adipokines & Leptin
All OSA Patients Should Not Be Treated
• OSA is associated with neuro-cognitive, cardiovascular, and metabolic complications.
• Rx favorably impacts all three domains.• CPAP is well tolerated in the Sleepy Sleep Apnea
phenotype with moderate to severely elevated AHIs.
• Observational and placebo controlled data confirms Rx robustly improves sleepiness as well as HRQOL.
• Observational and placebo controlled data* suggests that cardiovascular risk can be reduced with treatment.
Teşekkürler
All OSA Patients Should Not Be Treated
• Response
Treatment with Continuous Positive Airway Pressure Is Not Effective in Patients with Sleep Apnea but No Daytime SleepinessA Randomized, Controlled Trial Ann Intern Med. 2001;134:1015-1023
Treatment with Continuous Positive Airway Pressure Is Not Effective in Patients with Sleep Apnea but No Daytime SleepinessA Randomized, Controlled Trial Ann Intern Med. 2001;134:1015-1023
White Bars Pre RxGray Bars Post Rx
CPAP does not reduce blood pressure in non-sleepy hypertensiveOSA patients Eur Resp J (in press)