Obstructive Sleep Apnea

and Stroke Risk

Stroke Symposium December 2013

Lysa Boissé Lomax MD MSc FRCPC

Queen’s University

Divisions of Neurology and Respirology

Disclosure of Potential for Conflict of Interest

Stroke Symposium

Wednesday, December 4th, 2013

DISCLOSURE: No conflicts of interest

Lysa Boissé Lomax

Objectives

• Obstructive Sleep Apnea (OSA)

• Discuss link between OSA and Stroke

• OSA screening tools

• Treatment

Obstructive Sleep Apnea (OSA)

• Cyclic collapse of upper airway during sleep

• Cessation of airflow with hypoxemia or

hypercapnia

• Can result in arousal which terminates the event

• AHI (Apnea/hypopnea index)

– AHI < 5 (normal)

– AHI 5 -15 (mild)

– AHI 15 - 30 (moderate)

– AHI > 30 (severe)

Calvin Curr Opin Cardiol 2009; AASM Manual for the Scoring of Sleep and Associated Events

2007

Epidemiology

• Affects 2-15% of middle aged population

• 24% men 9% women

• >80% untreated/undiagnosed

Young N Engl J Med 1993; Mohensin Arch Phys Med Rehab 1995; Dyken Stroke 1996;

Bassetti Sleep 1999

Risk Factors

• Obesity

• Male gender

• Age > 50

• BMI > 35

• Neck circumference > 40cm

• Family history

– Small oropharyngeal airway

Kuipers NEJM 2012

Copyright © The American College of Cardiology.

All rights reserved.

From: Obstructive Sleep Apnea and Heart Failure: Pathophysiologic and Therapeutic Implications

J Am Coll Cardiol. 2011;57(2):119-127

Untreated OSA Increases Stroke Risk

• 4x the risk of general population

– 3x increased risk of MI

• Compared to patients with AHI<5

– Adjusted for risk factors such as age, gender, BMI,

smoking, HTN, hypelipidemia, diabetes, left

ventricular function

• 1 unit increase in AHI increases stroke risk by 6%

Valham Circulation 2008, Yaggi NEJM 2005, Artz Am J Respir Crit Care Med 2005; Buchner

Am J Respir Crit Care Med 2007; Marin Lancet 2005; Redline 2010

OSA and Hypertension

• OSA is associated with drug-resistant hypertension

• Correlation INDEPENDENT of other comorbidities

• TREATMENT of OSA can lower BP in patients with

resistant HTN

– 9.8mm Hg systolic

– 6.8 mmHg diastolic

Peppard NEJM 2000; Duran-Cantolla BMJ 2010; Lozano J Hypertension 2010; Demede 2011

Cardiac arrhythmias occur as a result of OSA

– Paroxysmal atrial fibrillation

– Non-sustained ventricular tachycardia

– Premature atrial complex

– Sinus bradycardia

– Sinus pauses

– Premature ventricular complexes

Cardiac Arrhythmia and OSA

• Increased sympathetic tone

• Atrial Fibrillation

– Pts with A fib more likely to have OSA

– 81.6% vs. 60%

• Presence of obstructive sleep apnea increased the

risk of atrial fibrillation recurrence after catheter

ablation

• Increased risk of nocturnal death

• Increased risk of death overall (4x)

Gami NEJM 2005; Leung Am J Respir Crit Care Med 2001; Yaggi 2005; Abe 2010

Stroke Exacerbates OSA

• 58%-62% of patients post-stroke or TIA snore

• AHI 27 vs. 12%(AHI 6) in general population

Chan Stroke 2010; Bassetti 1996

OSA Worsens Post-Stroke Recovery

• Acute/Subacute

– Early neurologic worsening in hemispheric stroke

– Treatment improves NIH Stroke Scale score 30

days post-stroke (-3 vs. -1)

• Chronic

– Decrease in functional independence

– 30% longer time in hospital

– Increased stroke recurrence

– OSA and neurocognitive impairment

Kaneko 2003; Iranzo 2002, Lal 2012; Bravata 2011

Screening for OSA

• Clinical history

– “Elbow Test”

– Witnessed

snoring/apnea

– Day time somnolence

– Nocturia

– Waking with a feeling

of choking/gasping

– AM headache

Fenton Chest 2013

Screening for OSA

• Clinical history

– “Elbow Test”

– Witnessed

snoring/apnea

– Day time somnolence

– Nocturia

– Waking with a feeling

of choking/gasping

– AM headache

• Questionnaires

– STOP / STOP-Bang

– Berlin Questionnaire

– Wisconsin Sleep

Questionnaire

Fenton Chest 2013

Screening Tools: Overnight Oximetry

Polysomnography (Overnight Sleep Study)

Treatment

• 2” x 4” under head of the bed

• Positional treatment

– Rematee Bumper Belt

Treatment

• 2” x 4” under head of the bed

• Positional treatment

– Rematee Bumper Belt

– Football in children’s backpack

• Breathe Right Nasal Strips

• Provent nose plugs

• Oral appliance

• Surgical alteration of soft palate

Treatment

Continuous

Positive Airway

Pressure (CPAP)

• CPAP Treatment reduces stroke risk by 60-70%

• NNT 5 over 7 years (CV events or sudden death)

Martinez-Garcia 2005 and 2012

CPAP Treatment

• Trouble shooting is key!

• CPAP Education Centre working with patient

Conclusion

• OSA is an independent risk factor for:

– Stroke

– HTN

– Cardiac arrhythmia

• Can be screened for

• Treatment reduces stroke risk by 60-70%

– Reduces systolic and diastolic blood pressure

– Reduces risk of sudden death

Questions?

References • Calvin AD and Somers VK. Obstructive sleep apnea and cardiovascular disease. Current Opinion in Cardiology 2009

• Somers VK et al., Sleep Apnea and Cardiovascular Disease. Circulation 2008

• AASM Manual for the Scoring of Sleep and Associated Events 2007

• Young T et al., The occurrence of sleep disordered breathing among middle-aged adults N Engl J Med 1993

• Artz M et al., Association of sleep disordered breathing and the occurrence of stroke. Am J Respir Crit Care Med 2005

• Valham F et al., Increased risk of stroke in patients with coronary artery disease: a 10 year follow-up. Circulation 2008

• Kuipers AF and Bartels LW. Sleep apnea. NEJM 2012

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• Mohensin V et al., Sleep apnea in patients with hemispheric stroke. Arch Phys Med Rehab 1995

• Dyken ME et al., Investigating the relationship between stroke and sleep apnea. Stroke 1996

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Care Med 2007

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observational study. Lancet 2005

• Peppard et al., Prospective study of the association between sleep disordered breathing and hypertension. NEJM

2000;

• Duran-Cantolla CPAP as treatment for hypertension in people with OSA. BMJ 2010;

• Lozano J et al., CPAP treatment in sleep apnea patients with resistant hypertension: a randomized controlled trial. J

Hypertension 2010

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