greg mauldin, md...2018/07/03 · osa and atrial fibrillation burden patel et al. 2010, n = 3000,...

GREG MAULDIN, MD

• Pulmonologists at Georgia Pulmonary Group• Practicing for 25+ years . • Speaker: Astra-Zeneca, Boehringer-Ingleheim, Jansen Pharmaceuticals, Sunovion Pharmaceuticals

• Board Certified in• Critical Care Medicine• Pulmonary Medicine

• Special Interests: Sleep Medicine

Residency/Fellowship:University of Tennessee

Memphis

MBA: University Tennessee-Knoxville

Medical School:Medical College Of Georgia

School Of Medicine

OSA: KILLING ME LOUDLY

Gregory L. Mauldin, MD, MBA, FCCP, FAASM

Georgia Pulmonary Group

Georgia Sleep Specialists

AGENDA

• Who does OSA kill?

• How does OSA Kill?

• How can we stop the killing?

QUESTION #1OSA IS ASSOCIATED WITH ALL OF THE

FOLLOWING EXCEPT

1. A. Female Gender

2. B. Obesity

3. C. Hypertension

4. D. Congestive Heart Failure

5. E. Atrial Fibrillation

77%

0%4% 2%

18%

1 2 3 4 5

QUESTION #1OSA IS ASSOCIATED WITH ALL OF THE

FOLLOWING EXCEPT

• A. Female Gender

B. Obesity

C. Hypertension

D. Congestive Heart Failure

E. Atrial Fibrillation

OBSTRUCTIVE SLEEP APNEA

Characterized by pauses or gaps in breathing due to an obstruction of the airway

OBSTRUCTIVE SLEEP APNEA

WHO DOES OSA KILL?

• Significant OSA is present in 15% of males and 5% of females

• Risk Factors:

• Age

• Male gender

• Obesity

• Craniofacial abnormalities

• CHF

• CVA

HOW DOES OSA KILL?

• Motor vehicle crashes 3X risk

• Cardiovascular complications

• Systemic arterial hypertension

• Pulmonary hypertension

• Coronary artery disease

• Arrhythmias

• Heart failure

• Stroke

HOW DOES OSA KILL?

• Diabetes

• Nonalcoholic fatty liver disease

• Perioperative complications

• Overall, OSA has a 2-3 x increased risk for all-

cause mortality

HIGH PREVALENCE OF OSA IN MAJOR CHRONIC DISEASES

Heart Failure 76%

Drug-Resistant Hypertension 83%

Coronary Artery Disease 57%

Stroke 63%

Depression 45%

Atrial Fibrillation 49%

Logan et al. J. Hypertension; O’Keefe and Patterson, Obes Surgery; Oldenburg et al,, Eur J Heart Failure; Einhorn et al. Endocrine Prac; Basseti et al. Stroke

Type 2 Diabetes 72%

Morbid Obesity 77%

OSA PREVALENCE AND SEVERITY

Mild OSAAHI: 5-15

Moderate OSAAHI: 15-30

Severe OSAAHI: ≥30

1. Peppard et al, Am J Epidemiology 20132. Young et al, SLEEP 2008, Figure 1

AHI: <5 and/or snoring

AHI < 5

AHI 5-15

AHI 15-30

AHI ≥ 30

67%

14%

5%

4%

OSA Prevalence in US adults (%)1 Untreated OSA affects mortality2

HOW DOES OSA KILL?

• Observational data identifies OSA as a significant risk factor for cardiovascular morbidity and mortality

• However, large prospective studies have failed to show the benefit of PAP

• Limitations of these studies include exclusion of “sleepy patients” and patients with hypoxemia and low adherence (3.3hrs) of PAP/night

• There was a trend toward improvement in cardiovascular outcomes in patients who wore PAP greater than 4 hours/night.

Months

• Untreated severe OSA (AHI > 30) increases risk

• Consistent CPAP treatment or an AHI <15 reduces risk

OSA TREATMENT REDUCES CV EVENTS*

Marin et al, Lancet 2005

* Spanish Sleep Cohort (n=1,651, mean follow-up of 10 yrs; age ~ 50 yr)

WHICH OF THE FOLLOWING OCCURS DURING NORMAL SLEEP?

1. A. Increase in blood pressure

2. B. Increase in glomerular filtration rate

3. C. Decrease in cardiac output

4. D. Decrease in growth hormone

5. E. Decrease in seizure threshold7%

26%

58%

2%

7%

1 2 3 4 5

0

WHICH OF THE FOLLOWING OCCURS DURING NORMAL SLEEP?

A. Increase in blood pressure

B. Increase in glomerular filtration rate

• C. Decrease in cardiac output

• D. Decrease in growth hormone

• E. Decrease in seizure threshold

HOW DOES OSA KILL?HYPERTENSION

• BP usually dips during sleep

• With OSA there is an increase in plasma and urinary

catecholamines

• Mild OSA is associated with twice the incidence of

HTN

• 71% of resistant HTN patients were found to have

OSA, compared to 38% of controlled HTN patients.

• Treatment with CPAP, oral appliances, and surgery all

have modest benefits.

HOW DOES OSA KILL?CORONARY ARTERY DISEASE

• Severe, untreated OSA associated with

CAD

• Mild OSA probably not associated with

CAD

• CPAP decreases fatal and non-fatal events.

• Benefit greatest in sleepy patients and with

at least 4 hours of CPAP use/night

HOW DOES OSA KILL?ATRIAL FIBRILLATION

• Autonomic dysfunction, hypoxia, hypercapnia, and increased negative thoracic pressure lead to increased juxtacardiac and transmural pressure of the thin walled atria

• Strong association, 4 fold higher odds, between OSA and AF independent of obesity and other confounders

• OSA may be a modifiable risk factor for recurrent AF after cardioversion or ablation.

OSA AND ATRIAL FIBRILLATION BURDEN

Patel et al. 2010, N = 3000, Post AF Ablation

Neilan TG et al. 2013, N = 720

• Atrial fibrillation (AF) is the most common cardiac arrhythmias

• 20 - 80% AF patients have OSA

• Treatment of OSA is associated with reduction of AF burden

CPAP

No CPAP

HOW DOES OSA KILL?SUDDEN CARDIAC DEATH

• Severe or untreated OSA may increase risk of fatal

cardiac arrhythmias

• Sleep without OSA is usually cardioprotective.

• OSA patients have a 3x increased risk of SCD

between 12MN and 6am compared to general

population without OSA, especially with low

SaO2.

HOW DOES OSA KILL?PULMONARY HYPERTENSION

• PH present in 20% of moderate-severe OSA

patients

• usually mild unless there is coexisting lung disease

• Other risk factors include: daytime hypoxemia,

AHI, obesity-hypoventilation syndrome

• Survival rates lower with OSA and pulmonary

HTN

• CPAP modestly improves pulmonary HTN

HOW DOES OSA KILL?VENOUS THROMBOEMBOLISM

• Risk of VTE 2-3 fold greater with OSA

• Increase in hypercoagulable markers

fibrinogen and plasminogen activator

inhibitor-1

• Endothelial dysfunction

• Unknown if CPAP helps.

HOW DOES OSA KILL?HEART FAILURE

• OSA may be seen in 50-75% of CHF Patients with reduced

EF

• Increased negative intrathoracic pressure can lead to

increased preload and increased left ventricular afterload.

• Neurohumoral effects cause pulmonary congestion leading

to hyperventilation and Cheyne- Stokes Respiration.

• Rostral neck edema can play a role in worsening OSA

• CPAP may improve cardiac function, BP, exercise capacity

and quality of life.

AN ARTICLE STUDYING 4.9 M DANES FOR 12 YEARS PUBLISHED IN THE JOURNAL OF THE AMERICAN HEART ASSOCIATION ON JUNE

22, 2018 SHOWED AN ASSOCIATION OF OSA AND WHICH OF THE FOLLOWING?

1.A. Sudden Cardiac Death

2.B. Congestive Heart Failure

3.C. Uncontrolled Hypertension

4.D. Atrial Fibrillation

5.E. Coronary Artery Disease

30%

3%

28% 28%

11%

1 2 3 4 5

0

AN ARTICLE STUDYING 4.9 M DANES FOR 12 YEARS PUBLISHED IN THE JOURNAL OF THE AMERICAN HEART ASSOCIATION ON JUNE

22, 2018 SHOWED AN ASSOCIATION OF OSA AND WHICH OF THE FOLLOWING?

• A. Sudden Cardiac Death

• B. Congestive Heart Failure

• C. Uncontrolled Hypertension

• D. Atrial Fibrillation

• E. Coronary Artery Disease

Sleep Apnea, the Risk of Developing Heart Failure, and

Potential Benefits of Continuous Positive Airway Pressure

(CPAP) Therapy

by Anders Holt, Jenny Bjerre, Bochra Zareini, Henning Koch, Philip Tønnesen,

Gunnar H. Gislason, Olav W. Nielsen, Morten Schou, and Morten Lamberts

J Am Heart Assoc

Volume 7(13):e008684

June 22, 2018

© 2018 Anders Holt et al.

Study population, inclusions and exclusions.

Anders Holt et al. J Am Heart Assoc 2018;7:e008684


Crude incidence rates of HF stratified by 10‐year age intervals and in 3 groups: background

population, SA patients not receiving CPAP therapy, and SA patients receiving CPAP therapy.

Anders Holt et al. J Am Heart Assoc 2018;7:e008684


Schematic representation of the potential bidirectional relationship between obstructive and

central sleep apnea sleep (OSA and CSA, respectively), and heart failure (HF).



Relationship between overnight change in leg fluid volume (LFV) and apnea-hypopnea index

(AHI) in patients with heart failure.



Working bidirectional model illustrating the potential for hypertension and heart failure to initiate

or exacerbate sleep apnea, by stimulating the sympathetic nervous system and sympathetically

mediate renin release to cause sodium and fluid retention, and the potential for sleep apnea to

cause or worsen hypertension and heart failure by such sympathetic stimulation, and by

causing repetitive increases in left ventricular wall tension during sleep.

Takatoshi Kasai et al. Circulation. 2012;126:1495-1510Copyright © American Heart Association, Inc. All rights reserved.

OSA: HOW CAN WE STOP THE KILLING?

• Diagnosis:

• HST for patients with a high pretest probability of

moderate to severe OSA

• HST should not be used for patients with COPD,

Class III or IV heart Failure or obesity-

hypoventilation syndrome or other significant

cardiorespiratory disease


• In-lab polysomnography is preferred for

patients with significant cardiorespiratory

disease


• CPAP is the mainstay of treatment

• Weight loss, bariatric surgery

• Dental appliance

• Surgical therapies

• Nerve stimulators

SUMMARYOSA KILLING ME LOUDLY

• OSA is very common

• Severe, symptomatic OSA is associated with cardiovascular morbidity and mortality but mild, asymptomatic OSA is probably not.

• Remains underdiagnosed, home sleep testing is a fast, inexpensive option in most patients, but not for those with significant cardiorespiratory disease

• CPAP remains best first option for most, but not for everyone, and we need to consider alternatives when appropriate

•

greg mauldin, md...2018/07/03 · osa and atrial fibrillation burden patel et al. 2010, n = 3000,...

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