Sleep Apnea Awareness, Treatment May Improve Some CVD Outcomes: AHA

Better recognition and diagnosis of obstructive sleep apnea (OSA) in cardiovascular medicine may help with symptom control and well-being, the American Heart Association (AHA) says. They’ve issued a new scientific statement hoping to increase recognition and diagnosis of OSA in cardiovascular practice.

The last AHA statement to address this topic was published in 2008, writing committee chair Yerem Yeghiazarians, MD (University of California, San Francisco), told TCTMD in an email.

“The hope is that this scientific statement will increase awareness about this condition,” he added. Approximately one-third of men and 17% of women have OSA. In those with cardiovascular disease, the prevalence is even higher at 40% to 80%.

The paper also provides updated guidance on how best to screen and manage patients suspected of having a sleep disorder, pointing to evidence that treatment has been shown to improve patient-centered outcomes, mood, and work productivity.

“Patients can now be screened for OSA using a home sleep study kit if they choose not to go to a sleep center for testing,” Yeghiazarians noted. “Also, since some patients refuse to wear the CPAP mask and/or are not tolerant of CPAP, there are alternate options of therapy such as an oral appliance, weight loss, positional therapy, lifestyle interventions, or other surgical methods that might be applicable for a given patient.”

Screening Advice Plus a Call for More Data

In the statement, published June 21, 2021, ahead of print in Circulation, cardiologists are advised to screen for OSA in patients with resistant/poorly-controlled hypertension, pulmonary hypertension, and recurrent atrial fibrillation (AF) following either cardioversion or ablation. A formal sleep assessment is considered reasonable in heart failure (HF) patients with New York Heart Association functional class II-IV and suspicion of sleep-disordered breathing or excessive daytime sleepiness, in order to distinguish sleep apnea that is obstructive from central sleep apnea (CSA), in which breathing repeatedly stops and starts during sleep. A sleep evaluation should also be considered for patients with tachy-brady syndrome, ventricular tachycardia, and survivors of sudden cardiac arrest in whom there is a suspicion of OSA. Others in whom the document advises sleep-apnea screening include patients with nocturnally occurring angina, MI, arrhythmias, or appropriate shocks from implanted cardioverter-defibrillators.

“A sleep history, ideally obtained with assistance from a bed partner, should include questions on frequency and severity of snoring, gasping, or snorting during sleep, frequent awakening or sleep disruption, and excessive daytime sleepiness, particularly difficulty maintaining alertness, involuntary periods of dozing, or drowsy driving,” Yeghiazarians and colleagues write.

Recommended tools for assessment include the Berlin Questionnaire, STOP-BANG, and STOP, but these should be used with the understanding that they may underperform in certain patient groups, including women and those with underlying CV disease, heart , AF, or stroke history. They add that “CPAP should be offered to patients with severe OSA, whereas oral appliances can be considered for patients with mild-to-moderate OSA or for CPAP-intolerant patients.”

The scientific statement also reviews what is known about the impact of OSA treatment in patients with various comorbid conditions. While they note some evidence of CPAP or other OSA therapies being associated with improvement in pulmonary artery pressure, pulmonary vascular resistance, stroke recovery, and cardiac dysrhythmias, data on patients with MI and HF and those treated with CPAP for primary stroke prevention are limited and unclear regarding specific benefits.

While severe OSA has been shown to increase all-cause and cardiovascular death in some studies, the impact of mild or moderate OSA on mortality is less clear, according to the statement. Also uncertain is how long patients need to be followed after starting OSA therapy to see a benefit on mortality. In the Sleep Heart Healthy Study, for example, patients with severe OSA and a prescription for CPAP had a 42% reduction in all-cause mortality that was not apparent until 6 to 7 years of follow-up.

Yeghiazarians and colleagues say wearables that track breathing, snoring, movement, heart rate, and oxygen saturation, as well as machine learning that processes and identifies actionable data, may be well-positioned to improve diagnosis and allow for personalized treatment of OSA. Additionally, while home diagnostic tools are available, these need improvement and should include unobtrusive sensors that can track other variables during sleep to bring at-home testing in line with in-laboratory sleep studies, they advise. Ongoing experimental areas for treatment alternatives to CPAP and oral appliances include chemoreceptor modulation and pharmacologic options.

“Better cardiovascular risk stratification in the patient with OSA is important,” they conclude. “Variables such as genotype, epigenetics, microRNA expression, and simple phenotypic measures such as sleepiness require further exploration.”