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Managing Hypertension through the Patient Centered Medical Home. Web Conference Series. 12 – 1 p.m., June 17, 2009. Hypertension & Obstructive Sleep Apnea Jacalyn A. Nelson, MD, Dean Health System. Sponsored by:. Agenda. Obstructive sleep apnea Hypertension Patient Centered Medical Home.

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Managing Hypertension through the Patient Centered Medical Home

Web Conference Series

12 – 1 p.m., June 17, 2009

Hypertension & Obstructive Sleep Apnea

Jacalyn A. Nelson, MD, Dean Health System

Sponsored by:

slide2

Agenda

  • Obstructive sleep apnea
  • Hypertension
  • Patient Centered Medical Home
definitions
Definitions
  • Obstructive Apnea
    • Cessation of airflow at least ten seconds in duration
    • With or without an oxygen desaturation or arousal
  • Central Apnea
    • No airflow
    • No effort to breathe
    • At least ten seconds in duration
  • Hypopnea
    • No universally accepted definition
    • Commonly – a 30% or greater airflow reduction accompanied by a 3% to 4% oxygen desaturation and arousal
    • At least ten seconds in duration
definitions4
Definitions
  • RERA (Respiratory Effort-Related Arousal)
    • Increased respiratory effort leading to an arousal
    • Does not meet the criteria for apnea or hypopnea
    • At least ten seconds in duration
definitions5
Definitions
  • Apnea/Hypopnea Index (AHI)
    • The number of apneas plus hypopneas per hour of sleep
  • Respiratory Disturbance Index (RDI)
    • The AHI plus RERAs per hour of sleep
  • Obstructive Sleep Apnea
    • RDI (or sometimes AHI) ≥ 5
anatomy
Anatomy
  • Pharyngeal Airway Patency
    • Balance between upper airway muscles and intraluminal pressure
craniofacial abnormalities
Craniofacial Abnormalities
  • Low-lying Soft Palate
  • Elongated or Widened Uvula
  • Tonsillar Hypertrophy
  • Macroglossia
  • Micrognathia
  • Retrognathia
  • Nasal Pathology
    • Deviated Septum
    • Turbinate Hypertrophy
craniofacial abnormalities8
Craniofacial Abnormalities
  • Low-lying Soft Palate
  • Elongated or Widened Uvula
  • Tonsillar Hypertrophy
  • Macroglossia
  • Micrognathia
  • Retrognathia
  • Nasal Pathology
    • Deviated Septum
    • Turbinate Hypertrophy
common presenting symptoms daytime
Common Presenting Symptoms - Daytime
  • Somnolence and/or fatigue
  • Napping
  • Drowsiness during daytime activities
    • Falling asleep at the wheel
    • Nodding off during meetings
  • High caffeine intake
  • Impaired memory and concentration
  • Irritability
  • Morning headaches
common presenting symptoms nocturnal
Common Presenting Symptoms - Nocturnal
  • Loud snoring
  • Witnessed apneas
  • Respiratory disturbances
  • Sleep maintenance difficulties
  • Diaphoresis
  • Sensation of choking or dyspnea
  • Nocturnal reflux
  • Nocturia
risk factors
Risk Factors
  • Obesity
    • BMI > 25
    • Android-type fat deposition
  • Age
    • > 65
  • Craniofacial Abnormalities
  • Behavioral Factors
    • Alcohol and Sedatives
    • Smoking
risk factors12
Risk Factors
  • Genetic Influences
    • Positive family history
    • African-American, Asian, Hispanic ethnicity
  • Associated Medical Conditions
  • Trisomy 21
  • Achondroplasia
  • Arnold-Chiari
  • Klippel-Feil
  • Pierre Robin
  • Marfan’s Syndrome
  • Hypothyroidism
diagnosis
Diagnosis
  • Quick Assessment Tool
    • Epworth Sleepiness Scale (Sleep, 1999)
      • Validated tool
  • Overnight Polysomnography
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Epworth Sleepiness Scale (ESS)

Use the following scale to choose the most appropriate number for each situation:

0 = would never doze or sleep

1 = slight chance of dozing or sleeping

2 = moderate chance of dozing or sleeping

3 = high chance of dozing or sleeping

Situation Chance of Dozing or Sleeping

Sitting and reading _____

Watching TV _____

Sitting inactive in a public place _____

Being a passenger in a motor vehicle for an hour or more _____

Lying down in the afternoon _____

Sitting and talking to someone _____

Sitting quietly after lunch (no alcohol) _____

Stopped for a few minutes in traffic while driving _____

Total Score (add up all scores) _____

adverse associations
Adverse Associations
  • Causes hypertension
  • Associated with
    • Stroke
    • Myocardial infarction
    • Sudden death at night
    • Right-sided heart failure
    • Cor pulmonale
    • Atrial fibrillation
    • Diabetes mellitus
    • Depression
epidemiology of sleep apnea
Epidemiology of Sleep Apnea
  • Current prevalence data inaccurate
  • Wisconsin Sleep Cohort Study (1993)
    • AHI > 5
    • 2% of women
    • 4% of men
  • Sleep Heart Health Study (1997)
    • RDI > 15
      • In this study, RDI = AHI
    • 22% of 1824 people
epidemiology of sleep apnea hypertension
Epidemiology of Sleep Apnea & Hypertension
  • 45% of patients with hypertension have sleep apnea
  • 80% of patients with drug resistant hypertension have sleep apnea
pathophysiology of sleep apnea hypertension
Pathophysiology of Sleep Apnea & Hypertension
  • Sympathetic activation is probably causal
    • Increased hypoxia and hypercapnea act through chemoreflexes to activate the sympathetic nervous system and vasoconstriction
    • When breathing resumes, there is an inspiratory increase in ventricular filling leading to increase in stroke volume
    • Vagolytic effects of inspiration cause tachycardia
    • Increased stroke volume and heart rate lead to increased cardiac output which enters vasoconstricted circulation

(Fletcher, J Sleep Res, 1995)

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Pathophysiology of Sleep Apnea & Hypertension

  • Other candidate mechanisms include:
    • Modification of the cardiovascular system in response to the large change in intra-thoracic pressure (Ehlenz, J Sleep Res, 1995)
    • Increased stress from sleep disruption (Guilleminault, J Sleep Res, 1995)
    • Endothelial dysfunction (Ip, Am J Respir Cri Care Med, 2004)
treatment
Treatment
  • CPAP is the most efficacious treatment for sleep apnea
  • CPAP may lower blood pressure
    • Approximate 10 mmHg drop in systolic and diastolic BP (Becker, et al., 2003)
composite patient
Composite Patient
  • 55 year old female w/ CC of snoring, restless sleep, fatigue and daytime sleepiness
  • Started antidepressants three years ago
  • Has gained 20 pounds
  • Past medical history
    • Impaired glucose
    • Depression
    • Hypothyroidism
composite patient23
Composite Patient
  • Exam
    • BP 136/82
    • Weight 170 pounds on a 5’5” frame
    • Oropharyngeal exam
      • Low-lying palate
      • Mild retrognathia
    • Otherwise unremarkable
  • Sleep schedule
    • Bedtime 10:30 or 11 PM
    • Wake time 5:30 AM
    • Awakening three to four times per night
    • Has difficulty getting back to sleep one to two times per week
  • ESS = 12
composite patient24
Composite Patient
  • Polysomnography
    • RDI = 18
    • Low oxygen saturation = 83%
  • CPAP titration
    • Titrated to 9 cmH2O
  • Patient returns to clinic
    • Feeling better
    • BP 126/78
conclusion
Conclusion
  • Sleep apnea is fairly common
  • Large impact on overall health
    • Causal role in the development of hypertension
  • Compelling evidence that treating sleep apnea lowers blood pressure
  • Patient Centered Medical Home
    • Identifying sleep apnea in patients
    • Monitoring CPAP compliance
slide26

Patient Centered Medical Home Overview

  • In a Patient Centered Medical Home:
  • Patients have a relationship with a personal physician.
  • A practice-based care team takes collective responsibility for the patient’s ongoing care.
  • The care team is responsible for providing or arranging all the patient’s health care needs.
  • The results are:
  • Better health outcomes
  • Lower costs
  • Greater equity in health
slide27

12 Components of the Patient Centered Medical Home

  •  After Hours Coverage
  •  Chronic Care Model
  •  Disease Registry
  •  Electronic Health Records
  •  Email with Patients
  • E-Prescribing
  •  Evidence-Based Clinical Guidelines
  •  Group Visits
  •  Office Redesign
  •  Open Access Scheduling
  • Quality Outcomes Measurements
  •  Team Approach
managing hypertension through the patient centered medical home

Hypertension & Obstructive

Sleep Apnea

Managing Hypertension through the Patient Centered Medical Home

CME Credit

This activity has been reviewed and is acceptable for up to 1 Prescribed credit by the American Academy of Family Physicians. To receive CME credit you must complete the pre- and post-test. The link for the post-test will be sent to your email address following the webinar.

If you do not receive the link by June 20, please contact Wisconsin Academy of Family Physicians Project Coordinator Sheri Urban at 262/512-0606 or email academy@wafp.org.

managing hypertension through the patient centered medical home30

Thank you for joining us for Hypertension & Obstructive Sleep Apnea. The next presentation in the series will be:

Hypertension & Chronic Kidney Disease

Paul S. Kellerman, MD, FACP

12-1 p.m., July 16, 2009

Explore the relationship between hypertension and chronic kidney disease with Paul S. Kellerman, MD, FACP, an Associate Professor of Medicine in the UW School of Medicine and Public Health Nephrology Division, the Director of ESRD and the Director of the UW Hypertension Clinic.

Managing Hypertension through the Patient Centered Medical Home

For more information on the Patient Centered Medical Home in Wisconsin, visit www.wafp.org/pcmh.

Thank you to Fred Petillo, Julie Shinefield, Cindy Huber and David Eitrheim, MD for their assistance in developing the webinar series.