A recent scientific statement from the American Heart Association (AHA) outlined screening, diagnosis, 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 CV complications have been implicated in OSA, including hypertension, 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 carries the potential for negative feedback, causing it to worsen CV conditions which may, in turn, worsen OSA.
According to the new AHA statement, OSA has been reported in 30% to 50% of people with hypertension. Up to 80% of patients with resistant hypertension may also have OSA. Research suggests OSA is an independent risk factor for hypertension and resistant hypertension. High blood pressure may or may not be a complication consequence of OSA.
In addition to hypertension, OSA has been demonstrated to be an independent risk factor for AF in patients without any other cardiac disorder. Both conditions share the same risk factors, such as obesity, hypertension, male sex, and increasing age.
Beyond AF and hypertension, OSA is also highly prevalent in patients with HF. Also, those with OSA and HF are at an increased risk for adverse outcomes associated with their CVD. The sleep disorder also independently increases the risk for, or is strongly associated with, other CVDs including coronary artery disease, cerebral vascular disease, and pulmonary hypertension.
Screening and Diagnosis
A significant lack in screening has caused OSA to fly well under the radar of many patients with CVD. There is an increasing push by the AHA and other relevant organizations to screen for OSA in more patients with CVD, given the evidence showing a high prevalence of OSA in patients with CVD as well as data demonstrating improved patient-centered outcomes, mood, and work productivity in relation to OSA treatment.
Clinicians could consider asking their patients and/or bed partner for a sleep history, based on answers to questions regarding snoring frequency and severity, gasping or snorting during sleep, frequent awakening during sleep, and excessive daytime sleepiness. Screening questionnaires for OSA include the Berlin Questionnaire, STOP-BANG (Snoring, Tiredness, Observed Apnea, Blood Pressure, Body Mass Index, Age, Neck Circumference, and Gender), and the STOP (symptoms of snoring, sleepiness, and other features associated with increased risk for OSA).
A caveat to some screening tools is their potential to underperform in certain groups of patients, the AHA noted. Groups in which OSA screening instruments may underperform include women, those who frequently report insomnia and fatigue symptoms, as well as patients with underlying HF, CVD, or AF.
For patients with resistant or poorly controlled hypertension, the AHA recommends clinicians consider enrolling the patient in a sleep study if the patient has New York Heart Association class 2 through 4 HF symptoms and concerning reported sleep apnea signs/symptoms.
The AHA also recommends a sleep study for patients with tachy-brady syndrome, ventricular tachycardia, or survivors of sudden cardiac death if these patients have suspected sleep apnea based on a comprehensive sleep exam.
Although OSA is associated with an increased risk for all-cause and CV mortality, the sleep-related disorder is largely underrecognized and undertreated in CV clinical practice, according to the AHA statement.
A common management 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 experience snoring or documented OSA.
Clinical trials suggest a lifestyle intervention approach consisting of a 10% weight loss can reduce apnea-hypopnea index (AHI) by up to 26%. Lifestyle changes could include modifications to diet, increased exercise, and a combination of the two. Ultimately, this approach should be considered complementary to more targeted OSA treatments while providing a foundation for improving sleep-disordered breathing as well as general health.
Continuous positive airway pressure (CPAP) is another common targeted OSA treatment that can concurrently improve blood pressure, subjective sleepiness, as well as quality of life. This therapy targets airway collapsibility, offering constant positive inspiratory and expiratory pressure.
The Centers for Medicare and Medicaid Services cover CPAP if a patient has AHI or Respiratory Event Index (REI) 15 events or more per hour or AHI (or REI) 5 or more in conjunction with symptoms of impaired cognition, excessive daytime sleepiness, insomnia, mood disorders, or comorbidities such as hypertension, ischemic heart disease, or stroke history.
Bilevel positive airway pressure may be helpful in patients who are either intolerant to CPAP pressure or who need additional ventilatory support. This therapy allows for the use of different pressures in inspiration and expiration. Oral appliances, the AHA added, should be considered for use in patients who are also intolerant to CPAP or who have mild to moderate OSA.
The AHA noted in the scientific statement that there is a significant need to further explore the use of wearable devices and remote monitoring tools for screening and treatment of OSA. In addition, better CV risk stratification protocols are needed for patients with OSA, the AHA concluded.
Disclosure: Several study authors declared affiliations with the pharmaceutical, biotech, or device industry. Please see the original reference for a full list of authors’ disclosures.
Yeghiazarians Y, Jneid H, Tietjens JR, et al. Obstructive sleep apnea and cardiovascular disease: A scientific statement from the American Heart Association. Circulation. Published online June 21, 2020. doi:10.1161/CIR.0000000000000988