A recent scientific statement from the American Heart Association (AHA) outlined screening, diagnostic, and treatment recommendations for obstructive sleep apnea (OSA) and cardiovascular (CV) complications associated with the sleep disorder. The statement was published online in Circulation.
The Link Between OSA and CV Disease (CVD)
Several cardiovascular complications have been linked to OSA, including high blood pressure, coronary artery disease, stroke, arrhythmias, heart failure (HF), and atrial fibrillation (AF). Metabolic syndrome and type 2 diabetes have also been reported in patients with OSA. The sleep disorder has the potential for negative feedback, which can cause cardiovascular conditions to worsen, which in turn can worsen OSA.
According to the new AHA statement, OSA has been reported in 30 to 50% of people with high blood pressure. Up to 80% of patients with resistant hypertension can also have OSA. Research suggests that OSA is an independent risk factor for high blood pressure and resistant hypertension. High blood pressure may or may not be a complication of OSA.
In addition to hypertension, OSA has been shown to be an independent risk factor for AF in patients without other heart disease. Both disorders share the same risk factors such as obesity, high blood pressure, male gender, and increasing age.
In addition to atrial fibrillation and hypertension, OSA is also very common in patients with HF. People with OSA and HF are also at increased risk of side effects related to their cardiovascular disease. The sleep disorder also independently increases or is strongly associated with the risk of other cardiovascular diseases, including coronary artery disease, cerebral vascular disease, and pulmonary hypertension.
Screening and diagnosis
A significant lack of screening has resulted in OSA landing well under the radar in many patients with CVD. The AHA and other relevant organizations are increasingly pushing for more patients with CVD to be screened for OSA, as the evidence shows a high prevalence of OSA in patients with CVD, as well as data showing improved patient-centered outcomes, mood, and work productivity in relation to OSA treatment.
Doctors may consider asking their patients and / or their bed partner about a sleep history based on answers to questions about the frequency and severity of snoring, wheezing, or snorting while sleeping, frequent awakenings while sleeping, and excessive daytime sleepiness. Screening questionnaires for OSA include the Berlin questionnaire, STOP-BANG (snoring, fatigue, observed apnea, blood pressure, body mass index, age, neck circumference and gender) and the STOP (symptoms of snoring, drowsiness and other related characteristics) with an increased risk of OSA).
One caveat about some screening tools is their potential to be too weak in certain patient populations, the AHA noted. Groups where OSA screening tools may underperform include women, those who frequently report insomnia and symptoms of fatigue, and those with underlying HF, CVD, or AF.
In patients with resistant or poorly controlled hypertension, the AHA recommends that clinicians enroll the patient in a sleep study if the patient has New York Heart Association grade 2 to 4 HF symptoms and if there are signs / symptoms of sleep apnea.
The AHA also recommends a sleep study for patients with tachy-brady syndrome, ventricular tachycardia, or sudden cardiac death survivors if those patients are suspected of having sleep apnea based on a comprehensive sleep assessment.
Although OSA is associated with an increased risk of all-cause and cardiovascular mortality, sleep-related disorder is largely underestimated and under-treated in cardiovascular disease in clinical practice, according to the AHA statement.
A common treatment option for OSA in patients with CVD includes lifestyle intervention and medical weight loss. This strategy can be most helpful in overweight or obese patients who primarily have snoring or documented OSA.
Clinical studies suggest that a lifestyle intervention approach consisting of 10% weight loss can lower the apnea-hypopnea index (AHI) by up to 26%. Lifestyle changes can include diet changes, more exercise, and a combination of both. Ultimately, this approach should be viewed as a complement to more targeted OSA treatments while providing a foundation for improving sleep-related breathing as well as overall health.
Continuous positive airway pressure (CPAP) is another common targeted OSA treatment that can improve blood pressure, subjective drowsiness, and quality of life at the same time. This therapy aims at the collapse of the airways and offers a constant positive inspiratory and expiratory pressure.
The Centers for Medicare and Medicaid Services will cover CPAP when a patient experiences AHI or Respiratory Event Index (REI) 15 events or more per hour or AHI (or REI) 5 or more associated with symptoms of impaired cognition, excessive daytime sleepiness, insomnia, A history of mood disorders or comorbidities such as high blood pressure, ischemic heart disease, or stroke.
Bilevel positive airway pressure can be helpful in patients who either cannot tolerate CPAP pressure or who require additional ventilation support. This therapy enables the use of different pressures during inspiration and expiration. Oral appliances, the AHA added, should be considered for use in patients who are also intolerant of CPAP or who have mild to moderate OSA.
The AHA noted in the scientific opinion that the use of portable devices and remote monitoring tools for the screening and treatment of OSA needs further investigation. In addition, better cardiovascular risk stratification protocols are needed for patients with OSA, the AHA concluded.
Disclosure: Several study authors stated links to the pharmaceutical, biotech, or device industries. For a full list of the author’s disclosures, see the original reference.
Yeghiazarians Y, Jneid H, Tietjens JR, et al. Obstructive Sleep Apnea and Cardiovascular Disease: A Scientific Opinion from the American Heart Association. Traffic. Published online June 21, 2020. doi: 10.1161 / CIR.00000000000000988
This article originally appeared on The Cardiology Advisor