Sleep Apnea: Sleep Apnea: … … the heart suffers even in our sleep... the heart suffers even in our sleep... Adrián Baranchuk Adrián Baranchuk Associate Professor of Medicine and Physiology Associate Professor of Medicine and Physiology Queen’s University Queen’s University Kingston, Ontario, Canada Kingston, Ontario, Canada Cosme Argerich Hospital Symposium Cosme Argerich Hospital Symposium October 2010 October 2010
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Sleep Apnea: …the heart suffers even in our sleep... Adrián Baranchuk Associate Professor of Medicine and Physiology Queen’s University Kingston, Ontario,
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Sleep Apnea: Sleep Apnea:
……the heart suffers even in our sleep...the heart suffers even in our sleep...
Adrián BaranchukAdrián BaranchukAssociate Professor of Medicine and PhysiologyAssociate Professor of Medicine and Physiology
4.4. Mixed theory: central + obstructiveMixed theory: central + obstructive
The link between SA and cardiovascular morbidityThe link between SA and cardiovascular morbidity
1.1. Physiologic changes during sleepPhysiologic changes during sleepa.a. In NREM stage: BP and HR drop (10-20%): ↓ of MV and TPR, In NREM stage: BP and HR drop (10-20%): ↓ of MV and TPR,
↓ ↓ sympathetic tone in phase 4 of NREMsympathetic tone in phase 4 of NREMb. In REM stage: vasoconstriction + fluctuation of MV and HR b. In REM stage: vasoconstriction + fluctuation of MV and HR
2.2. Acute changes during SAAcute changes during SA
a.a. HR:HR: there are 2 patterns of behavior there are 2 patterns of behavior- Bradycardia at the onset of apnea, acceleration during SA - Bradycardia at the onset of apnea, acceleration during SA (chemoreceptors) and acceleration peak at the end of apnea (chemoreceptors) and acceleration peak at the end of apnea and when awakening and when awakening (more frequent)(more frequent)-- Progressive bradycardia along the apnea
b. BP: increase at the end of apnea (> desaturation, ↑ , ↑ sympathetic tone by sudden awakening)sympathetic tone by sudden awakening)
c.c. Minute volume:Minute volume: ↓ ejection volume during apnea ↓ ejection volume during apnea accompanied by intrapleural negative pressureaccompanied by intrapleural negative pressure
Pathophysiologic mechanisms Pathophysiologic mechanisms of cardiovascular morbidityof cardiovascular morbidity
Sleep Apnea
In summary…In summary…
SASA
Fluctuations of BP, HR and minute volume + Desaturation 02
Sleep Apnea:Sleep Apnea:SA and ArrhythmiasSA and Arrhythmias
What has been proven from all of this?What has been proven from all of this?
Sleep Apnea:Sleep Apnea:SA and ArrhythmiasSA and Arrhythmias
The association between SA The association between SA and AF is highly significant. and AF is highly significant. SA is also associated to SA is also associated to ventricular arrhythmias.ventricular arrhythmias.
Sleep Apnea:Sleep Apnea:SA and AFSA and AF
Sleep Apnea
Tachyarrhythmias Bradyarrhythmias
Atrial overdrivepacing
Heart failure
• Supra/ventricular arrhythmia• ? CRT
Autonomic dysfunction
• Atrial Fibrillation• Ventricular arrhythmia
• Systemic hypertension• Pulmonary hypertension
Stroke
Baranchuk et al. Europace 2008; 10(6):666-667 Baranchuk et al. Europace 2008; 10(6):666-667
Sleep Apnea :Sleep Apnea :SA and ArrhythmiasSA and Arrhythmias
Baranchuk et al. Europace 2008; 10(6):666-667 Baranchuk et al. Europace 2008; 10(6):666-667
AF + SA
HypertensionHypertension
Autonomic ImbalanceAutonomic Imbalance
Bi-atrial enlargement*Bi-atrial enlargement*
Heart failureHeart failure
? CAD? CADInteratrial block*Interatrial block*
Baranchuk A et al. Rev Electrofisol y Arrit 2008;1:5-6Baranchuk A et al. Rev Electrofisol y Arrit 2008;1:5-6 *Interatrial Block in Patients with OSA*Interatrial Block in Patients with OSABaranchuk et al Cardiol J;2010,in Press)Baranchuk et al Cardiol J;2010,in Press)
Sleep Apnea:Sleep Apnea:SA and ArrhythmiasSA and Arrhythmias
Zwillich C. J Clin Invest 1982;69:1286-92Zwillich C. J Clin Invest 1982;69:1286-92
• Bradycardia during SA•The greater the apnea, the greater the bradycardia•No bradycardia in absence of SA
Baranchuk et al. Case Reports Med 2009Baranchuk et al. Case Reports Med 2009
ECG recording of polysomnography is
a single lead and at times, it may be
confusing. In this case, the patient was
referred due to 2:1 block and in fact,
these are premature contractions
of the RV outflow tract.
Sleep Apnea:Sleep Apnea:Management with PacemakerManagement with Pacemaker
Sequential pacemaking did not show benefits in patients with SA
JACC 2006;47:379-83JACC 2006;47:379-83
Atrial overdrive pacing: 12 RCT since 2002…Atrial overdrive pacing: 12 RCT since 2002…
• The benefits are not clear…The benefits are not clear…
Baranchuk et al. Europace 2009. Baranchuk et al. Europace 2009.
Reduction of AHI in 5 points:Reduction of AHI in 5 points:Statistically significant but…Statistically significant but…No clinical relevance!!!No clinical relevance!!!
Baranchuk et al. ICRJ 2008;2(1):10-13Baranchuk et al. ICRJ 2008;2(1):10-13
(n=6424)(n=6424)AHI divided into quartilesAHI divided into quartilesMultivariate analysis and adjusted by co-variablesMultivariate analysis and adjusted by co-variables
Milleron O. Eur H Journal 2004;25:728-734Milleron O. Eur H Journal 2004;25:728-734
• (n=54)• Patients on SA + CAD• CPAP/ surgery vs no treatment• Composite end-point: cardiovascular mortality, ischemic event, hospitalization by CHF, revascularization
Treatment No treatment6/25 (24%) 17/29 (58%)HR 0.24 (95% CI 0.09 – 0.62)
P<0.01
Who is worried about this…?Who is worried about this…?
AUGUST 2008 (On-LINE)AUGUST 2008 (On-LINE)
Sleep Apnea:Sleep Apnea:StrokeStroke
Investigating the Relationship Between Stroke and Obstructive Sleep Apnea
1.1. SA (AHI>10): 55%SA (AHI>10): 55%2.2. Time of decelerationTime of deceleration
(p<0.05)(p<0.05)
Chest 1997,111:1488-93Chest 1997,111:1488-93
SA & Heart FailureSA & Heart FailureClinical scenariosClinical scenarios
(n=24)(n=24)
Non-randomized studyNon-randomized study
Ambulatory polygraphAmbulatory polygraph
1. Significant reduction of AHI (pre CRT vs post CRT)2. Significant increment of SaO2 3. Significant reduction of PSQI (Pittsburgh Sleep Quality Index)
JACC 2004,44:68-71JACC 2004,44:68-71
SA & Cardiac Resynchronization TherapySA & Cardiac Resynchronization Therapy
SA & HypertensionSA & HypertensionGreat population studiesGreat population studies
Wisconsin Sleep StudyWisconsin Sleep Study11: (n=709), follow up until 8 years: (n=709), follow up until 8 yearsSleep Heart Health StudySleep Heart Health Study22: (n=6841), follow up 3 years: (n=6841), follow up 3 years
1.1. N Engl J Med 2000;342:1378-84N Engl J Med 2000;342:1378-842.2. JAMA 2000;283:1829-36JAMA 2000;283:1829-36
The greater the severity of SA, the association with HTN is The greater the severity of SA, the association with HTN is increasedincreased
The question is: The question is: is there causality?is there causality?
SA & HypertensionSA & HypertensionPathophysiologyPathophysiology
The link between SA and LVH could be The link between SA and LVH could be hypertension, however, hypertension, however, it is present in children and teenagers with SAit is present in children and teenagers with SA
• (n=60)(n=60)• 3 grupos: AS severa, AS leve, control3 grupos: AS severa, AS leve, control• AS severa: AHI > 20AS severa: AHI > 20• Holter de 24 Hs con VFCHolter de 24 Hs con VFC
- Análisis en dominio de frecuencia- Análisis en dominio de frecuencia
- Análisis en dominio de tiempo- Análisis en dominio de tiempo• Ajustado para edad, BMI, FEyAjustado para edad, BMI, FEy