Cardiology and Sleep
• Gerald Weisfogel, MD, FACC, FAASM
Disclosures
• Medical Director Healthy Heart Sleep
• Speaker for Respironics
MAJOR DISCLOSURE
I AM PASSIONATE ABOUT THIS
FIELD!!!!
DON’T GO TO SLEEP----
PEOPLE TEND TO DIE THERE
Mark Twain
LONG TERM CV OUTCOMES IN
MEN WITH OSA
10 YEAR OBSERVATIONAL
STUDY. THOSE WITH SEVERE
OSA HAD 2.87 TIMES THE
LIKELIHOOD OF FATAL AND
3.17 TIMES THE LIKELIHOOD OF
NON FATAL CV EVENTS
COMPARED WITH HEALTHY
PARTICIPANTS
MARIN
LANCET, 365, 3/05
MORTALITY FROM OSA
Wisconsin SleepCohort Study
• 18 year follow up of 1522 middle aged
patients ages 30-60
• All cause mortality- 2-3 times greater in
those with OSA vs. no OSA
• Cardiovascular mortality- 5-6 times greater
Day Night Pattern of Sudden Death
in OSA
•
•
•
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•
Midnight to 6AM
OSA patients
No OSA
General Population
Chance
46%
21%
16%
25%
8-h Epochs of MI Occurrence
Sert Kuniyoshi, F. H. et al. J Am Coll Cardiol 2008;52:343-346
Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply.
Impact of SDB on Life Threatening
Arrhythmia in HF Pts with AICDs
• 71 pts with HF and ICD studied for 180 days after a sleep
study (all with EF<35%)
• 66% had SDB
• Appropriate shocks in 43% with SDB vs 17% without
SDB
• Shocks from 12 AM to 6 AM in 34% of SDB vs 17%
without SDB
Thus SDB in pts with HF and ICDs is an independent
predictor of life threatening arrhythmia more likely to
occur during sleep
Serizawa et al, JACC, 10/15/08
TAKE HOME MESSAGE
• Pts with OSA have 3-6 X likelihood of
fatal and non fatal CV events in 10-18 years
and 2-3 X all cause mortality vs those
without OSA.
• Pts with OSA have AICD shocks during the
night, MIs during the night and die during
the night. Not the case with non OSA pts.
NEJM: 11/10/2005
• SLEEP- A NEW CARDIOVASCULAR
FRONTIER
V.K.SOMERS
MAYO CLINIC
AHI AND RDI LIMITS REDEFINED
NEW CMS GUIDELINES FOR CPAP:
OSA EQUALS AHI OR RDI = 15 OR MORE
OR
AHI OR RDI FROM 5-14 WITH SYMPTOMS OF EDS,
IMPAIRED COGNITION, INSOMNIA
OR HYPERTENSION, IHD, OR CVA HX
TAKE HOME MESSAGE
IN OSA PATIENTS
• R-R interval decreases
• R-R variability decreases
• BP variability increases
ALL 3 predispose to the
development of cardiovascular disease
(Framingham data)
Usui et al., JACC 6/21/05
• CPAP attenuates sympathetic activation
in patients with OSA and optimally treated
CHF (beta blockers, ACEI etc.)
IMPLICATION: Untreated OSA in such
patients may be as harmful as suboptimal
treatment with beta blockers!
CRP IN HEART FAILURE
• CRP LEVELS AT ACUTE HEART
FAILURE ADMISSION PREDICTS
LONG TERM MORTALITY
• AM. HEART JOURNAL 4/3/ 2006
Intrathoracic Pressure Changes
• Increases transmural gradients across the
atria, ventricles, and aorta
• Consequences: increased wall stress,
increased atrial size, impaired diastolic
function, thoracic aortic
dilatation/anuersym, aortic dissection
Acronym for OSA and CHF
•
•
•
•
A---O---O---E----
Acronym for OSA and CHF
•
•
•
•
A---O---O---E----
AFTERLOAD
OVERLOAD
OVERNIGHT
EVERYNIGHT
…Prevalence of SDB in CHF
patients treated with Beta Blockers
Macdonald et al, Journal of Clinical
Sleep Medicine 2/2008
Heart Failure Patients
108 Consecutive
SDB in 61%
CSR in 31%
OSA in 30%
Difference between Groups with and
without SDB
Atrial Fibrillation
SDB
21%
No SDB
2%
Differences between CSR and OSA
groups
•
CSR
• NYHA
• Class II-------- 44%
• Class III-IV--- 56%
• LVEF%---------- 15%
• A-Fib------------ 28%
•
OSA
• NYHA
• Class II---------- 70%
• Class III-IV---- 30%
• LVEF%---------- 24%
• A-Fib------------- 8%
Sleep Apnea and Mortality in Heart
Failure. Wang et al, JACC 4/2007
218 Patients in HF
Clinic 1997-2005
117 (54%) Mild or
No OSA
56 (26%) OSA
45 (21%) CSA
56 OSA Patients
41 Untreated
15 Treated
4 Lost to FU
1 Lost to Follow up
Mortality Rates (mean 2.9 years)
• 1. Mild or No OSA
12%
• 2. Untreated OSA
24%
• 3. Treated OSA
0%
Sleep Monitoring at CHF Clinic
MD, NP, or PA
Assessment with
Sleep questionnaire
Smart Card monitoring
Watch PAT
PRESIDENT WILLIAM H. TAFT
• YALE UNIVERSITY, CINCINATTI LAW
SCHOOL
• GOVERNOR OF THE PHILIPPINES
• SECRETARY OF WAR
• PRESIDENT OF THE UNITED STATES
• CHIEF JUSTICE OF THE SUPREME
COURT
• As I gazed at him, knowing him to be
Brahms, I was utterly unable to recognize
the man I had known ten years
previously. There, indeed, was the
• great head with the hair brushed back as
of old, though less tidily than in former
days; but his figure had become much
heavier, and both mouth and chin were
hidden by a thick moustache and shaggy,
grizzled beard that had completely
transformed his appearance.
•
Florence May 1881
Johannes Brahms (1833-97)
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•
•
•
•
One of 3 great “B” composers (Bach, Beethoven,
Brahms)
Never married- although deeply loved Robert
Schumann’s wife Clara
His traveling companion insisted on separate
rooms because he snored loudly
Never wore neckties because neck was so large
Was irritable and nasty- “If there is anyone here I
have not offended, I apologize”