Cardiovascular Consequences of Sleep Apnea

Shahrokh Javaheri, MD, FCCP

Emeritus Professor of Medicine
University of Cincinnati College of Medicine
Medical Director, Sleepcare Diagnostics
Mason, Ohio

Central sleep apnea (CSA) may occur in a variety of disorders, most commonly in congestive heart failure, but is also seen in patients taking opioids and those with certain neuromuscular diseases. CSA does not necessarily respond to continuous positive airway pressure (CPAP); studies have found that nearly half of patients with CSA and comorbidities do not respond, and the non-responders have heightened rates of mortality. A Canadian study found excess early mortality in CPAP nonresponders, and found that the long term adherence to CPAP averaged only about 4 hours.[1] Bi-level positive airway pressure (BiPAP) auto SV Advanced technology has been designed to address this problem and be more patient friendly. They provide two levels of pressure: inspiratory PAP and a lower expiratory PAP. When the patient experiences obstructive events, the expiratory pressure will increase; when pressure returns to normal, the expiratory pressure and the pressure support will decrease, varying pressure in concert with the patient’s intrinsic rhythm. BiPAP autoSV Advanced devices minimize adverse hemodynamic effects of CPAP, which can include increased intrathoracic pressure, hypertension, coronary ischemia, and altered cardiovascular function, in which a decrease in the venous return to the right ventricle may result in an eventual decrease in stroke volume from the left ventricle. A significant percentage of congestive heart failure patients also have OSA, which generally is responsive to CPAP. The Wisconsin Cohort Sleep study, begun nearly 3 decades ago, has shown that patients with severe OSA, with an apnea-hypopnea index (AHI) at 30/hr or higher, have a cardiovascular hazard ratio for mortality at about 5, which is improved with CPAP use.[2] The study also found that those with mild (AHI 5 to 15/hr) and moderate (AHI 15 to 30/hr) OSA who are CPAP responders also benefit with reduced mortality when compared with nonresponders.

References

Arzt, M., et al., Suppression of central sleep apnea by continuous positive airway pressure and transplant-free survival in heart failure: a post hoc analysis of the Canadian Continuous Positive Airway Pressure for Patients with Central Sleep Apnea and Heart Failure Trial (CANPAP). Circulation, 2007. 115(25): p. 3173-80.
Young, T., et al., Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin sleep cohort. Sleep, 2008. 31(8): p. 1071-8.

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