All OSA Patients Should Not Be Treated Patrick J. Strollo, Jr., M.D., FCCP, D,ABSM University of Pittsburgh Medical Center Turkish Thoracic Society 9 th Annual Congress
Jan 22, 2016
All OSA Patients Should Not Be Treated
Patrick J. Strollo, Jr., M.D., FCCP, D,ABSMUniversity of Pittsburgh Medical Center
Turkish Thoracic Society9th Annual Congress
All OSA Patients Should Not Be Treated
• Define Obstructive Sleep Apnea
• What is the impact of treatment?
• Who benefits from treatment?
• What are the barriers?
Sleep Apnea is Associated with Significant Co-morbidities
Cardiovascular Complications
MetabolicComplications
Neuro-cognitiveComplications
Obstructive Sleep Disordered Breathing
• Mild: 5 – 15 events per hour• Moderate: 15 – 30 events per hour• Severe: > 30 events per hour
Level 2 Evidence Variable(s) on which the severity rating is based have been demonstrated to have a statistically significant relationship with excess morbidity in a prospective cohort study that has properly controlled for important covariates.
Sleep 199922:667-689
AASM Levels of Recommendation
AASM Classification of Evidence
All OSA Patients Should Not Be Treated
• Define Obstructive Sleep Apnea
• What is the impact of treatment?
• Who benefits from treatment?
• What are the barriers?
Current evidence that treatment impacts outcome
• CPAP is indicated for the treatment of moderate to severe OSA (Standard)
• CPAP is indicated for improving self reported sleepiness in patients with OSA (Standard)
• CPAP is recommended for the treatment of mild OSA (Option)
• CPAP is recommended for improving quality of life in patients with OSA (Option)
• CPAP is recommended as an adjunctive therapy to lower blood pressure in hypertensive patients with OSA (Option)
Sleep 200629:375-380
Effect of CPAP on Daytime Function
• Design: Double blinded, randomized, controlled trial
• Patients: CPAPther n =54, CPAPsham n=53• Outcome variables: Subjective sleepiness (ESS),
Objective sleepiness (MWT), SF-36
Lancet 1999Lancet 1999
353:2100-05353:2100-05
CPAPther 5.4 hours/nightESS: 15.5 => 7.0 *MWT: 22.5 => 32.9 * SF-36: 35.4 => 73.0 *
CPAPsham 4.6 hours/nightESS: 15.0 => 13.0 *MWT: 20.0 => 23.5 SF-36: 33.9 => 50.9 *
Results
* P < 0.001* P < 0.001
Effect CPAP on Blood Pressure
• Objective: Compare change in BP in men with OSA
• Design:: Randomized parallel trial
• Subjects: ODI 41.4 + 20• Outcome variable: Change
in mean BP at 4 weeks• Results: NCPAPther
decreased BP 2.5 mm Hg vs. NCPAPsubther 0.8 mm Hg– Effect was greater in
patients taking antihypertensive meds
Lancet 2001359:204-10
A BP fall of 3.3 mm Hg would be expected to be associatedwith a stroke risk reduction of about 20% & a coronary heartdisease event risk reduction of about 15%
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Effect of CPAP on Afib Recurrence
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Control OSA Treated OSA Untreated
Circulation 2003107:2589-94
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n = 79 n = 12 n = 27
53% 42%
82%
p = ns
p = 0.013
p = 0.009Population
Patients referred for cardioversionAge 65 + 10 yrsMale (81%)BMI 37 + 11AHI: 45 + 38 (treated) 34 + 29 (untreated)
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AIM: Observational study to compare incidence of fatal and non-fatal cardiovascular events in simple snorers, patients with untreated OSA,patients treated with CPAP, and healthy men recruited from the general population.Design: Prospective observational cohort. 264 healthy men, 377 simple snorers, 403 with untreated mild-moderate OSA (AHI 5-30), 235 with untreated severe OSA (AHI > 30), and 372 with OSA and treated with CPAP
Lancet 2005 365: 1046–53
MonthsMonths
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Conclusion: In men, severe OSA significantly increases the risk of fatal and non-fatal cardiovascular events. CPAP treatment reduces this risk.
Long-term cardiovascular outcomes in men with OSA
AHI 43.3 + 5.7
AHI 42.4 + 4.9
AHI 18.2 + 3.5
All OSA Patients Should Not Be Treated
• Define Obstructive Sleep Apnea
• What is the impact of treatment?
• Who benefits from treatment?
• What are the barriers?
Vulnerable populations
• Phenotypes– Severe apnea (AHI > 30)– Individuals < 55 years– Women?– Coexisting CV disease
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AIM: Observational study to compare incidence of fatal and non-fatal cardiovascular events in simple snorers, patients with untreated OSA,patients treated with CPAP, and healthy men recruited from the general population.Design: Prospective observational cohort. 264 healthy men, 377 simple snorers, 403 with untreated mild-moderate OSA (AHI 5-30), 235 with untreated severe OSA (AHI > 30), and 372 with OSA and treated with CPAP
Lancet 2005 365: 1046–53
MonthsMonths
.
Conclusion: In men, severe OSA significantly increases the risk of fatal and non-fatal cardiovascular events. CPAP treatment reduces this risk.
Long-term cardiovascular outcomes in men with OSA
AHI 43.3 + 5.7
AHI 42.4 + 4.9
AHI 18.2 + 3.5
Arch Intern Med 2002 162:893-900
Prevalence of an AHI > 15 by age
Impact of Gender on Survival
AHI < 5 AHI > 5
Thorax 199853:s16-19
n = 190
n = 32
n = 73
n = 59
Years
Dea
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in T
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sGender Difference in Cardiovascular Mortality
Women
Men
Source: CDC / CHS
Effect of OSA Rx on Cardiac Events
• Design: Prospective observational study (86.5 + 39 months)
• Patients:– N = 54 (53 M / 1 F)– Age 57.3 + 10.1– CAD (> 70% stenosis)
& AHI > 15• Endpoints:
– Cardiovascular death– Acute coronary artery
syndrome– Hospitalization for CHF– Coronary Artery
Revascularisation• Results:
– Treated 6/25 (24%)– Untreated 17/29 (58%)
p < 0.01
EHJ 200425:728-34
Treated n = 25
Untreated n = 29 E
ven
t-fr
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urv
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Time (months)
AHIbase 33.7 + 16.8
AHIbase 29.0 + 12.8
Cost Effectiveness of CPAP
Aims: To determine the short-term and long-term impacts of CPAP on HRQL in patients OSA.Design: Prospective longitudinal cohort study.Patients: Three hundred sixty-five patients with an AHI > 20 per hour of sleep and 358 patients with an AHI of < 20.Interventions: All patients with AHIs > 20 received CPAP therapy; those with AHIs < 20 did not. The HRQL of all study participants was measured using the SF-36 questionnaire at baseline and then at 3 and 12 months.
CHEST 2002122:1679–1685
Months of Follow-up
Vit
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Conclusions: CPAP therapy was associated with marked short-term and long-term improvements in the vitality of patients with moderate- to- severe OSA in the community. These findings suggest that CPAP therapy is effective in improving the long - term HRQL of patients with OSA.
All OSA Patients Should Not Be Treated
• Define Obstructive Sleep Apnea
• What is the impact of treatment?
• Who benefits from treatment?
• What are the barriers?
Sleep Apnea: Treatment Options
• Lifestyle– Fitness– Avoid sleep deprivation, Alcohol, Sedatives– Lateral position or Elevated HOB
• Medical – Positive Pressure via a mask
• CPAP • Bi-level pressure
• Oral appliances• Surgical
– Upper airway bypass (trach)– Upper airway reconstruction
• Phase 1 : UPPP & Genioglossal advancement• Phase 2: Maxillomandibular advancement
Medical- Positive Pressure via a mask
• CPAP• Bi-level pressure
Factors Affecting CPAP Adherence
• Snoring history.
• Apnea / hypopnea index ( > 30).
• Epworth sleepiness score ( > 10).
Prospective evaluation of CPAP use (n = 1,211)
Adherence at 5 yrs (68%): 3 month use predictive
AJRCCM 1999159:1108-14
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Apnea – Hypopnea Index
The Relationship of Self Reported Sleepiness to Sleep Apnea
n = 4653
Non-Sleepy Sleep Apnea
Sleepy Sleep Apnea
Obesity
Sleep Apnea Diabetes
LV Hypertrophy
Pleiotrophic Effects of Adiopkines on Vascular Risk
Adipokines & Leptin
All OSA Patients Should Not Be Treated
• OSA is associated with neuro-cognitive, cardiovascular, and metabolic complications.
• Rx favorably impacts all three domains.• CPAP is well tolerated in the Sleepy Sleep Apnea
phenotype with moderate to severely elevated AHIs.
• Observational and placebo controlled data confirms Rx robustly improves sleepiness as well as HRQOL.
• Observational and placebo controlled data* suggests that cardiovascular risk can be reduced with treatment.
Teşekkürler
All OSA Patients Should Not Be Treated
• Response
Treatment with Continuous Positive Airway Pressure Is Not Effective in Patients with Sleep Apnea but No Daytime SleepinessA Randomized, Controlled Trial Ann Intern Med. 2001;134:1015-1023
Treatment with Continuous Positive Airway Pressure Is Not Effective in Patients with Sleep Apnea but No Daytime SleepinessA Randomized, Controlled Trial Ann Intern Med. 2001;134:1015-1023
White Bars Pre RxGray Bars Post Rx
CPAP does not reduce blood pressure in non-sleepy hypertensiveOSA patients Eur Resp J (in press)