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CONSEQUENCES OF SLEEP APNEA SYNDROME Yüksel Peker MD, PhD, Associate Professor Sleep Medicine Unit, Skaraborg Hospital, Skövde & University of Gothenburg, Sweden. Wife stabbed snoring husband. rescued by thoracic surgeons. OSA (Asymptomatic OSA; “Non-sleepy sleep apnoeics”)

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CONSEQUENCES OF

SLEEP APNEA SYNDROME

Yüksel Peker

MD, PhD, Associate Professor

Sleep Medicine Unit, Skaraborg Hospital,

Skövde & University of Gothenburg, Sweden


Wife stabbed snoring husband

rescued by thoracic surgeons



Obstructive sleep apnea syndrome osas osa daytime sleepiness treatment indication
OBSTRUCTIVE SLEEP APNEA SYNDROME (OSAS) OSA + Daytime sleepinessTreatment indication


Prevalence (30-60 yrs) Men Women OSA 24 % 9 % OSAS 4 % 2 % The majority of the patients with OSA do not report daytime sleepiness


Eight-year follow-up AHI versus baseline AHI in the Wisconsin Sleep Cohort Study (n= 282) Young Tet al, AJRCCM 2002


Bixler et al ajrccm 1998

Bixleret al, AJRCCM 1998

%

Do they

  • become asymptomatic?

  • die?


OSA

  • Immediate changes

  • Long-term effects


OSA

  • Immediate changes

  • Long-term effects



Cardiovascular mechanisms (I)

Repeated nocturnal hypoxemia

Coccogna G et al, 1972; Podszus T et al, 1986

Sympathetic nervous activity

Fletcher EC et al, 1987; Hedner J et al, 1988;

Narkiewicz K & Somers VK 2003

Vascular endothelial dysfunction

Carlson J et al, 1996; Remsburg S et al, 1999;

Kraiczi H et al, 2000


Cardiovascular mechanisms (II)

Enhanced release of superoxide from polymorphonuclear neutrophils in OSA. Impact of CPAP.

Schulz Ret al, AJRCCM 2000

Plasma vascular endothelial growth factor in OSAS: Effects of CPAP.

Lavie L et al, AJRCCM 2002

Elevated levels of C-reactive protein and interleukin-6 in patients with OSAS are decreased by CPAP.

Yokoe Tet al, Circulation 2003


Pulse-oximetry

Oxygen

saturation %

Heart rate

50 %

Time


Osa cvd
OSA & CVD

  • Immediate changes

  • Long-term effects


Hypnogram
Hypnogram

Lights Out

MT

Normal

Wake

REM

S1

S2

S3

S4

00:00

02:00

04:00

06:00

08:00

OSA

Lights Out

MT

Wake

REM

S1

S2

S3

S4

00:00

01:00

02:00

03:00

04:00

05:00

06:00

07:00


Long term complications
Long-term complications

  • Cognitive dysfunction

  • Cardiovascular dysfunction


AHI 30

AHI 30

AHI 30

AHI 30

AHI 30

AHI 30


Long term complications1
Long-term complications

  • Cognitive dysfunction

  • Cardiovascular dysfunction


Clinical and epidemiological aspects

Obstructive sleep apnea is associated with

Hypertension

Coronary heart disease

Cardiac arrhythmias

Heart failure

Stroke

Diabetes and Insulin Resistance

Mortality


CVD

OSA

OSAS


CVD

OSA

Obesity



Prevalence of CAD in Sleep Clinic Cohorts

CAD in 25% of unselected patients with OSA

More common in severe OSA

Maekawa M et al, Psychiatry Clin Neurosci 1998


First author publ yr

n

AHI10

controls

De Olazabal 1982

Andreas 1996

Mooe 1996

Mooe 1996

Koehler 1996

Peker 1999

Moruzzi 1999

Sanner 2001

Mehra 2006

Takama 2007

Yumino 2007

17

50

142

102

74

62

22

49

104

65

89

76 %

50 %

37 %

30 %

35 %

31 %

9 %

27 %

66 %

45 %

57 %

yes

yes

yes

Total

776

42%

Prevalence of OSA in CAD clinic cohorts


Explanatory variables associated with CAD (multivariate analysis) _______________________________________________________________________________________Odds Ratio 95 % CI p values_______________________________________________________________________________________Current smoking 9.8 2.6-36.5 0.001Diabetes mellitus 4.2 1.1-17.1 0.045Obstructive sleep apnea 3.1 1.2-8.3 0.025_______________________________________________________________________________________

Peker et al, ERJ 1999


Prognosis of CAD with concomitant OSA is WORSE than the analysis)

prognosis of CAD patients without OSA

Peker et al, AJRCCM 2000

Mooe et al, AJRCCM 2001

Yumino et al, Am J Cardiol 2007


Prognosis of CAD after PCI in patients with analysis)

concomitant OSA

89 consecutive patients with acute coronary syndrome who were successfully treated with PCI

OSA in 51 patients (57%); follow-up period 6 months

Major cardiac event (cardiac death, reinfarction, revascularization)

23.5 % in OSA, 5.3 % in non-OSA (p=0.020)

Odds ratio for OSA 11.6 (95% CI 2.2-62-2)

Yumino et al, Am J Cardiol 2007




Prognosis of CAD with concomitant OSA is analysis)

NOT WORSE than the prognosis for CAD patients

without OSA

50 CAD patients (25 OSA, 25 non-OSA)

Follow-up period 10 years

Cardiac death in 4 versus 5 patients (ns)

Hagenah et al, Respir Med 2006


Weak association between OSA & CAD analysis)

in a general population

Sleep Heart Health Study

Cross-sectional analysis (n=6,132)

Adjusted OR for OSA 1.27 (95% CI 0.99-1.62)

(AHI>11 versus AHI<1.4)

Shahar E et al, AJRCCM 2001


CAUSALITY analysis)

Incident CAD in OSA

Impact of treatment of the OSA on CAD


All normotensive at baseline analysis)

AJRCCM 2002


CAD incidence in a sleep-clinic cohort analysis)

at a 7-yr follow-up

%

Peker et al, ERJ 2006


Probability of CAD incidence estimated by Poisson model analysis)Start age 49 yrs, Systolic BP 133 mmHg and Sat. min 86%

Peker et al, ERJ 2006


OSA & Stroke analysis)


First author publ yr analysis)

n

AHI10

controls

Bassetti 1996

Dyken 1996

Bassetti 1999

Wessendorf 2000

Parra 2000

Iranzo 2002

Hui 2002

Turkington 2002

Kaneko 2003

Bassetti 2006

59

24

128

147

161

50

51

120

61

152

69 %

71 %

63 %

44 %

71 %

62 %

67 %

61 %

72 %

58 %

yes

yes

Total

953

67%

Prevalence of sleep apnea in acute stroke/TIA


Sleep apnea improves after the acute phase of stroke analysis)

Normalizing in 40% of the patients within 6 months

Bassetti CL et al, Stroke 2006; 37:967-972


Early neurologic worsening in acute stroke and analysis)

sleep apnea

50 patients with acute stroke underwent polysomnography (first night)

62% had AHI10

Early neurologic worsening occurred in 30%

Sleep apnea and serum glucose predicted early neurologic worsening

No difference in functional outcome after 6 months

Iranzo A et al, Neurology 2002; 58:911-916


Increased 6-month mortality (37%) in patients with analysis)

stroke and sleep apnea

120 patients enrolled

Turkington PM et al, Thorax 2004; 59: 367-371


OSA is a risk factor for death in patients with stroke analysis)

10-year follow-up

132 patients (1995-1997) were enrolled

Obstructive Sleep Apnea (AHI15) in 23

Central Sleep Apnea in 28

116 had died at follow-up

Adjusted OR for death was 1.76 (95% CI 1.05-2.95) for OSA

No correlation with central sleep apnea

Sahlin C et al, Arch Intern Med 2008; 168:297-301


Association between OSA & stroke in a general population analysis)

Sleep Heart Health Study

Cross-sectional analysis (n=6,132)

Adjusted OR for OSA 1.58 (95% CI 1.02-2.46)

(AHI>11 versus AHI<1.4)

Shahar E et al, AJRCCM 2001


PREVALENCE of STROKE analysis)

General population: 1475 subjects

Arzt M et al, AJRCCM 2005; 172:1447-1451


INCIDENT STROKE analysis)

General population: 1189 subjects - at 4-yr follow-up

Arzt M et al, AJRCCM 2005; 172:1447-1451


OSA & Mortality analysis)


Long-term cardiovascular outcomes in men with OSA with or without treatment with CPAP: an observational study

Marin JM et al

Lancet 2005; 365:1046-53


  • Long-term cardiovascular outcomes in men with OSA with or without CPAP

  • Sleep clinic (1992-1994), PSG 1465

  • Simple snorers (n=377)

  • OSA (n=1071)

  • CPAP recommended (n=667)

  • CPAP accepted (n=426)

  • Untreated severe OSA (AHI>30, n=235)

  • Healthy controls (n=264) individually matched with the severe untreated OSA for age and BMI (AHI<5)


Cardiovascular events in men during 10 years without CPAP

%

***

***

modified from Marin JM et al, Lancet 2005


Fully adjusted Odds Ratios for cardiovascular death associated with clinical variables

OR (95% CI) p

Age, yrs 1.09 (1.04-1.12) 0.001

Snoring 1.03 (0.31-1.84) 0.88

Mild OSA 1.15 (0.34-2.69) 0.71

Severe OSA 2.87 (1.17-7.51) 0.025

CPAP 1.05 (0.39-2.21) 0.74

Cardiovascular disease 2.54 (1.31-4.99) 0.005

Marin JM et al, Lancet 2005


Conclusions i
CONCLUSIONS (I) associated with clinical variables

  • Recurrent obstructive events during sleep have harmful effects on daytime vigilance as well as on vascular structure and function

  • Epidemiological data suggest an independent association between OSA and CVD in the clinical cohorts while the association is weaker in the general population

  • Not only may OSA induce CVD but also the events in themselves may worsen the prognosis of an already existing CVD


Conclusions ii
CONCLUSIONS (II) associated with clinical variables

  • OSA should be included among factors considered in the primary and secondary prevention models of CVD.

  • OSA should be treated not only to eliminate daytime sleepiness. Treatment may also have a beneficial prognostic impact by reducing cardiovascular morbidity in OSA.


Thank you for your attention! associated with clinical variables


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