does treating sleep apnea help the heart? · learning objectives • recognize the relationships...

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

Presenter

Presentation Notes

High prevalence of obstructive sleep apnea, affects 35% of men and 17% of women and is largely undiagnosed. Modifiable CVD risk factor. CSA is rare in the general population but is common in patients with HF, CVA, AF. Recent data also suggests that CSA is a risk factor for AF and HF

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

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwinjsS0ucrKAhWCeSYKHWWkBAAQjRwIBw&url=http://www.celebritydiagnosis.com/2011/03/its-national-sleep-awareness-week/&psig=AFQjCNH1DOvZiHbJP6Lrt4F-GkkPPm5Cmw&ust=1453999725212556

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

Presenter

Presentation Notes

Oft-cited Spanish study from 2005. Prospectively observed cohorts of age- and BMI- matched controls (264), snorers (377), untreated mild-mod OSA (403), severe untreated disease (235) and severe CPAP-treated disease (372). All were followed for 10 years for fatal MI or stroke, non-fatal MI, non-fatal stroke, CABG or PCI.

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

Presenter

Presentation Notes

German study. 449 consecutive sleep lab patients (mostly men) followed for median 72 months for fatal and non-fatal cardiac events (death from MI or stroke, MI, stroke, need for revascularization). Relatively risky group with prior CAD and diabetes. At all levels of OSA event free survival was better in treated patients but most events were revascularizations. All: 28 vs 14%, p=0.009. Mild-moderate: 25 vs 14%, p=0.024.

Ref: Barbé F et al. JAMA 2012; 307: 2161.

CPAP Therapy & Cardiac Events: RCT Data

Presenter

Presentation Notes

Spanish study. 725 patients with no CAD history and AHI ≥ 20 with low ESS (≤10) randomized to CPAP or not. Main outcomes were incident hypertension or cardiac event (non-fatal MI, non-fatal stroke, TIA, ACS hospitalization, heart failure, CV death). Majority of events were incident hypertension. CPAP compliance mattered. Focus on CPAP compliance in this trial and discuss as a problem with OSA management in general.

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 & 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

Presenter

Presentation Notes

Study from Singapore. PSG done on 120 consecutive patients admitted with STEMI.

Baseline Post treatment

Ref: Pepperell JC et al. Lancet 2002; 359:204. OSA and Heart Disease 2016

Hypertension: CPAP Effect – RCT

Presenter

Presentation Notes

Randomized study to CPAP vs. sham CPAP in 118 men, all with OSA and desats. Most robust improvement was if AHI severe (mean 33). Data shown are mean ambulatory BP readings over 24 hours, obtained at 30 minute intervals.

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

Presenter

Presentation Notes

Prospective observational study. 164 consecutive HF patients received PSG and followed for survival. Grouped as mild-to-no SA (n= 113, mean AHI 7), untreated OSA (n=37, mean AHI 32) and treated OSA (n=14, mean AHI 36). Top is Cox proportional hazard evaluation. Bottom is multivariate hazard analysis.

CPAP & Heart Failure Survival - CSA

Ref: Bradley TD et al. N Engl J Med 2005; 353: 2025. OSA and Heart Disease 2016

Presenter

Presentation Notes

CANPAP study. 258 patients with CSA (moderate; AHI mean 20) and heart failure (mean LVEF 25%, age 63) randomized to CPAP + meds vs. meds only. 5 years of follow up for lifestyle, labs and transplant-free survival. No difference in survival.

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


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


SUMMARY

does treating sleep apnea help the heart? · learning objectives • recognize the relationships...

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