ReviewObstructive Sleep Apnea and Cardiovascular Disease
Section snippets
MORTALITY ASSOCIATED WITH OSA
Studies done several years ago found that OSA seemed to be associated with an increase in morbidity and mortality. He et al18 reported that approximately 40% of patients with severe OSA died during a follow-up period of 8 years. Treatment with continuous positive airway pressure (CPAP) and tracheostomy improved survival, but uvulopalatopharyngoplasty did not. However, the study was retrospective, had follow-up of only 54% of patients enrolled, and lacked information about cause of death. Other
HYPERTENSION AND OSA
An association between OSA and hypertension has been observed since the early clinical description of OSA in the 1970s.22, 23, 24, 25 Several studies have suggested that the prevalence of hypertension is higher than expected in patients with OSA and that OSA occurs frequently in patients with hypertension.23, 24, 26 The importance of this observation is that an association between hypertension and OSA would provide a mechanistic link for the increase in cardiovascular mortality seen with OSA.
STROKE AND OSA
A higher than expected incidence of OSA in patients who have had a stroke has been observed. In a case-control study, Partinen and Palomaki42 found that the relative risk of stroke in snorers compared with nonsnorers was 10.3. Palomaki et al43 observed an odds ratio of 8.0 for stroke in individuals with a history of OSA after adjustment for hypertension, obesity, alcohol consumption, and coronary heart disease. Spriggs et al44 reported that a history of snoring was associated with a relative
CORONARY HEART DISEASE AND OSA
Current evidence indicates that OSA occurs commonly in patients with coronary artery disease, is associated with nocturnal angina and nocturnal ST-T segment depression, and adversely affects outcome. Additionally, OSA is an independent risk factor for ischemic heart disease. Hung et al59 reported that in patients with myocardial infarction OSA was as strong a risk factor as obesity, smoking, and hypertension. In one study, clinically important OSA was evident in 50% of patients with coronary
CONGESTIVE HEART FAILURE
Obstructive sleep apnea has been associated with idiopathic cardiomyopathy and congestive heart failure (CHF).66, 67 Although OSA has been noted frequently in patients with CHF, whether the prevalence differs from that expected in a closely matched population without heart failure is unclear. Sleep-disordered breathing in patients with CHF can be primarily obstructive due to upper airway collapse, primarily central (Cheyne-Stokes respirations [CSR], central sleep apnea), or a combination of
CARDIAC ARRHYTHMIAS
An increased incidence of both bradyarrhythmias and tachydysrhythmias has been associated with OSA and is likely related to the severity of OSA and degree of hypoxemia associated with apneic events.91, 92 Severe bradycardia and atrioventricular block are seen frequently in association with OSA. These arrhythmias are most likely explained by the vagal response that occurs in response to apneic events.93, 94 The increase in vagal tone causes slowing of atrioventricular conduction and bradycardia.
PULMONARY HYPERTENSION
Although it is generally accepted that pulmonary artery (PA) pressure rises immediately in response to hypoxemia in patients with OSA, there is no general consensus that OSA alone can cause daytime pulmonary hypertension because most early studies did not adequately control for the presence of underlying cardiac or pulmonary disease. Diurnal pulmonary hypertension in patients with OSA has been found to correlate more with a lower daytime PaO2 and higher PaCO2 than with severity of OSA.100
POSSIBLE MECHANISMS OF CARDIOVASCULAR DISEASE IN OSA
Mechanisms that might explain a relationship between OSA and cardiovascular disease have been investigated extensively (Table 2). Hemodynamics are significantly different during normal sleep and sleep complicated by periodic obstructed breathing. During normal sleep, the decrease in heart rate and blood pressure is approximately 10% to 15%, which is likely mediated by an overall increased vagal activity and decreased vascular sympathetic traffic.106 Cardiac output declines about 10% in normal
SUMMARY
Obstructive sleep apnea is common in the general population and has been implicated in adverse cardiovascular effects. It is associated with hypertension, and treatment with CPAP reduces both nocturnal and daytime blood pressure, in part by attenuating sympathetic nervous activity. Obstructive sleep apnea appears to be a potential risk factor for ischemic heart disease, has been associated with nocturnal ST-segment depression in patients with coronary heart disease, and may affect outcome
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Dr Somers has served as a consultant for ResMed Inc and Respironics, Inc and spoken at symposia sponsored by unrestricted educational grants from ResMed Inc, Respironics, Inc, Guidant Corp, and Medtronics, Inc.