MORE ZZZZZZZZ PLEEEZE!

TO SLEEP PERCHANCE TO DREAM

PERCHANCE TO DIE • SNORING

• SLEEP APNEA

• HYPERTENSION CHF

• ARRHYTHMIAS

• AND OTHER GOOD STUFF

SLEEP

• Most require between 6-10 hours/day – Average adult 7.5-8.0 hrs/day

– Greater or lesser sleep duration is assoc. with a shorter life span

• Sleep deprivation is common – Technology, societal pressures, sleep disorders

– Great expense to society • Motor vehicle accidents

• Decreased productivity

Sleep Stages

• Non-REM sleep(75-80%) – Stage 1(5%) – Stage 2(50%) – Stage 3-4*(15-20%)

• REM sleep (20-25%) (*3/4 sleep=slow wave sleep=delta sleep)

Sleep-Disordered Breathing A Brief Review

• New definitions (CMS, AASM SHHS 2001) – Apnea:

• 70% reduction in airflow for 10 seconds

– Hypopnea • 30% reduction in airflow with 4% desat for 10 sec

• Obstructive sleep apnea hypopnea syndrome (OSAHS=SDB=OSA) – AHI=RDI greater than or equal to 5 with

symptoms

Dionysius of Herculea- Fourth Century BC

• (I am informed that Dionysius…..through daily gluttony and intemperance, increased to an extraordinary degree of corpulency and fatness, by reason whereof he had much ado to take breath)

• Therapy-fine long needles thrust through belly and ribs

How We Got Joe

• 1822 - William Wadd “Cursory Remarks on Corpulence”

• 1877 - First accurate account by W. H. Broadbent in England

• Joe the Fat Boy in “The Pickwick Papers” by Charles Dickens

Symptoms

• EDS • Snoring • Headache • Hypertension • Restless sleep • Hypercapnia • Pulmonary HTN • RVH • Polycythemia • GERD • Impotence

Respiratory Disturbances

• Increased in males after age 35

• Increased in females after menopause

SNORING

•Who

•Why

•Where

•When

•How

At Risk Population

• Obese males or females

• History of loud snoring

• Hypothyroid

• Children with oropharyngeal abnormalities

GENDER DIFFERENCES

•Males

-EDS, Bad Sleep, Loud Snoring

•Females -Daytime Fatigue, HA, Mood Prob

Diagnostic Studies

• PSG

– EOG, Sleep Stages, EEG, Chin EMG

– Body Position

– ECG

– Respiratory Effort

– SaO2

– Air Flow

Therapy

• Weight Loss • BPR • Tracheostomy • Surgery • Nasal CPAP

Sleep-Disordered Breathing and Hypertension

• Normal blood pressure and heart rate response to sleep is to decline 10% (10-20 mmHg – Those who don’t are “nondippers” – Nondipping carries risk of

• Ventricular arrhythmias • Cardiac hypertrophy • Sudden cardiac death (in women)

SDB and Hypertension

• Higher AHI equals higher A.M. blood pressure

• SDB converts “dippers” to “non-dippers”

• Results in increased cardiac stress

SDB and Hypertension

•OSA in 40-60%

•Drug resistant 90% have OSA

•Effective CPAP Improves HTN

•Ineffective CPAP does not

Overall Cardiovascular Response to Normal Sleep

• Fall in epinephrine

• Fall in heart rate

• Fall in morning BP (morning dip)

• Fall in cortisol (until 5 a.m.)

• Sympathetic activity declines

• Overall arrhythmogenicity falls

SDB and Heart Attack

• OSA is a risk factor in MI

• Mortality much higher if AHI>20

• Known Cardiac pts. and severe OSA

– 5x greater mortality over time

SDB and Heart Attack

•Silent Cardiac Damage

•Non Dippers have Higher Mortality

- 20% higher in one study

OSA and CHF

•Stress on R & L Ventricles

•Enlargement and Failure

•Up to 75% Have OSA

CHF and OSA

• Worse quality of life

• Worse cardiac function over time

• Increased mortality

• CPAP improves all of above

• Many patients were not sleepy

ARRHYTHMIAS

•Causes

- Decreased O2

- Sympathetic Activity

- Non Dipping

- Cardiac Stretch

Arrhythmias and OSA

•Atrial Fibrillation 49%

•Ventricular Events 60%

•Sudden Cardiac Death 2X

•CPAP Improves all of above

Pulmonary hypertension

• Incidence-20% of patients with SDB(OSA)

• Risk Factors

-Obesity

-Decreased O2 Saturation

-Smoking

• Nasal CPAP improves pulmonary HTN

Summary

• Sleep reduces cardiac risk in normals

• REM sleep is a vulnerable time for cardiac patients

• OSAHS causes cardiovascular disease – Hypertension, systemic and pulmonary

– Ischemic events

– Arrhythmias

– CHF

• Beta blockers disrupt sleep, but save lives

• CPAP reduces cardiac risk of SDB

RIP VAN WINKLE

“Don’t ever go to sleep. Too many people die there.”

Mark Twain

QUESTIONS

Thank you

Tim Lieske M.D.

402-474-3704