Cardiology and Sleep Gerald Weisfogel, MD, FACC, FAASM.

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 OSAWisconsin 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

• Midnight to 6AM

• OSA patients 46%

• No OSA 21%

• General Population 16%

• Chance 25%

Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply.

Sert Kuniyoshi, F. H. et al. J Am Coll Cardiol 2008;52:343-346

8-h Epochs of MI Occurrence

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---- AFTERLOAD

• O---- OVERLOAD

• O---- OVERNIGHT

• E---- 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

4 Lost to FU

15 Treated

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

Smart Card monitoringMD, NP, or PA

Assessment withSleep questionnaire

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)

• 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”