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Obstructive sleep apnea is related to various types of cardiovascular disease. Cardiologist Dr. Michael Faulx and Dr. Reena Mehra, Director of Sleep Disorders Research in the Sleep Center, have worked together to investigate this relationship. It is important to ask the right questions and look for risk factors to determine if there are underlying sleep disorders in the patient with cardiovascular disease. The STOP-BANG questionnaire can be used to test for high probability for sleep apnea but there are limitations. Testing for sleep apnea can be done at home – or in lab; and there are many ways it can be treated. Treating sleep apnea can improve cardiovascular disease, especially atrial fibrillation and high blood pressure.

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Sleep Apnea and Cardiovascular Disease

Podcast Transcript

Announcer:
Welcome to Cleveland Clinic Cardiac Consult brought to you by the Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute at Cleveland Clinic.

Michael Faulx, MD:
Hi, my name is Dr. Michael Faulx. I am a cardiologist in the Clinical Cardiology Section here at the Cleveland Clinic. I have a number of interests and one of my chief interests, both clinically and from a research point of view, has been the relationship between heart disease and obstructive sleep apnea.

Reena Mehra, MD, MS:
And I'm Dr. Reena Mehra, Director of Sleep Disorders Research in the Neurologic Institute and Professor of Medicine. Also have a very strong interest in the relationships of sleep disordered breathing and sleep disorders in general, as it relates to cardiovascular disease with a focus on cardiac arrhythmias and atrial fibrillation. And over the last 15 years or so I have been focused on research efforts to better understand those interrelationships.

Michael Faulx, MD:
And Dr. Mehra and I have known each other for quite a while, and we've collaborated on research projects and have shared patients over the years. And so I think that our practices sort of complement one another pretty well. What a lot of patients and even practitioners don't realize is how common obstructive sleep apnea or sleep disorder breathing is in patients with any sort of cardiovascular disease. The two problems are very intertwined at multiple levels. And so I think finding patients requires a certain degree of curiosity and an awareness that even though they may not volunteer to you that they're having difficulties waking up in the middle of the night with difficulty breathing, or that their wife or husband no longer sleeps in the room with them because they snore too loudly or they're having difficulties falling asleep or falling behind at work. That they have these complaints, in my practice I've come to realize that sleep apnea is so common in patients with cardiovascular disease that it's become a part of my routine screening questionnaire for every patient that I see.

Michael Faulx, MD:
So I ask them questions about sleepiness, about snoring, about morning headaches, everything that are sort of associated with obstructive sleep apnea. And also interviewing their bed partners in the office is an important step in that. And that's where you find these people. And they're not hard to find in the Heart and Vascular Institute. You just have to remember to look.

Reena Mehra, MD, MS:
Absolutely. And I think that it's wonderful to have these collaborations across cardiology and sleep medicine to be able to care for our patients. And as you said, Dr. Faulx, the standard symptoms that we oftentimes think about are snoring, tiredness, observed apneas, high blood pressure as far as risk factors, elevated body mass index greater than 35, age greater than 50, neck circumference that's enlarged in men greater than 17 inches, in women greater than 16 inches, and male gender.

Reena Mehra, MD, MS:
And those are all the components of a common screening instrument called the STOP-BANG instrument that we oftentimes use. And if there's three or more of those factors that are positive then folks are considered to be at high pre-test probability for obstructive sleep apnea. But we recognize as well that there are limitations to how our standard screening approaches work in the cardiac population. So patients with underlying cardiovascular disease, we are recognizing have different symptom profiles. And we may be if anything, kind of scratching the surface and maybe even missing folks by using our standard approaches. And I think we need more research in that area to better understand what factors we should specifically be looking for in our screening process for those with underlying cardiac disease.

Michael Faulx, MD:
Yeah. I agree. Not everybody complains of profound symptoms of obstructive sleep apnea. You certainly do meet those people where their day-to-day life is so adversely affected by their sleepiness, that when you finally get them diagnosed and get them treated, it can be sort of a life changing event for them. But I also use the STOP-Bang questionnaire in my office practice. And I'll meet people who qualify for screening who may not tell me about a lot of excessive sleepiness, but they have a lot of underlying cardiovascular disease that I know personally is associated with the presence of obstructive sleep apnea. And if they're not terribly symptomatic, these are the ones that require a little bit more coaching in terms of the importance of treatment. And I find that their cardiovascular disease can be a big motivator.

Michael Faulx, MD:
I have patients who complain constantly about having difficult to control high blood pressure and taking so many pills for their blood pressure. And those that end up with significant obstructive sleep apnea, I'll tell them that there's credible evidence that sleep apnea is a potent driver of high blood pressure and treating it might make your blood pressure easier to control. And it's strongly associated with virtually any cardiovascular illness, but I think hypertension and rhythm disorders in particular, atrial fibrillations specifically, there's a very strong correlation. And so for the ones that aren't horribly sleepy, I still might convince them to entertain the notion of treatment and diagnosis just by virtue of potentially making their cardiovascular illnesses easier to treat.

Reena Mehra, MD, MS:
Absolutely. And I think that helps when we have that partner to approach, because oftentimes if I tell a patient, oh, this is the treatment plan. It's sometimes more convincing when it comes from their cardiologist and they really drive home that key point that the treatment of that sleep disorder or sleep disorder breathing really can help their cardiovascular outcomes as well.

Michael Faulx, MD:
Yeah, certainly. So one question that I get in my office practice, if I screen somebody in and I do a home sleep apnea test or refer them to an in-lab polysomnogram and they end up with the diagnosis of obstructive sleep apnea, I get a lot of eye-rolls and groaning when I bring up CPAP or positive pressure airway management. And I think that part of it is that the patients don't fully understand that there's different modes, that there's different types of mass and there's different treatment options. I was wondering if you could elaborate, even educate me on sort of the breadth of things that one can offer to treat sleep apnea aside from what they consider to be what they call the Darth Vader mask?

Reena Mehra, MD, MS:
Yes. So it is challenging. So, obstructive sleep apnea by sheer virtue of the pathophysiology involving upper airway collapse, which can occur at different sites of the airway that is behind the tongue, behind the pallet or below, is most amenable to positive airway pressure because positive airway pressure splints all aspects of the airway, irrespective of where the collapse is occurring. And so that is why it is our go-to and typical first line treatment for obstructive sleep apnea. There are other treatment options to consider. Upper airway surgery has been considered an option such as uvulopalatopharyngoplasty, where the soft palate and uvula are removed. The outcomes with that are not very good. It's a coin flip, a 50/50 chance as to whether that's going to effective in treating the obstructive sleep apnea. So that is oftentimes not a route we go and sleep apnea tends to recrudesce or recur over time, even if there happens to be some improvement with that intervention.

Reena Mehra, MD, MS:
Other options that are being increasingly considered and used are oral appliances. So if patients have milder or even maybe moderate degrees of obstructive sleep apnea, the oral appliance is an option as it works by advancing the mandible. So there are these mandibular advancement devices that need to be custom made, and that happens in partnership with an orthodontist or dentist that's trained to do so. And we happen to have some great colleagues here that we work with to do that.

Reena Mehra, MD, MS:
And now what we're finding also is this hypoglossal nerve stimulation, which can be an option for those who have more severe degrees of obstructive sleep apnea. And so for those that are perhaps less obese, who have, again, more severe degree of obstructive sleep apnea, then this upper airway neurostimulation device can actually be very effective in treating that sleep apnea. Recognizing there has to be certain anatomical characteristics that are conducive for that particular intervention. And it may not be all those who have severe sleep apnea who are ideal candidates, but under the evaluation of an ear, nose, throat doc and sleep specialist, we can basically do some testing to figure out what kind of collapse of the airway there is and what phenotype the patient has, and whether they'll be amenable to the neurostimulation.

Michael Faulx, MD:
That's great. That's a great review. I have a lot of patients that have read about the hypoglossal nerve stimulator and because it's kind of fancy and high-tech, I think that there's a lot of interest in it. But as you say, people who qualify for it or who might benefit from it, there's a screening process that unfortunately limits a lot of people in terms of who qualifies.

Reena Mehra, MD, MS:
And it's really interesting. You and I have published in this area. There's not a lot of data in terms of the effect of hypoglossal nerve stimulation on cardiovascular outcomes, such as blood pressure. But we did a study where we compared those who had positive airway pressure compared to hypoglossal nerve stimulation, and simply looked at blood pressure as the outcome and found that interestingly, those who had positive airway pressure intervention were more likely to have blood pressure reduction than those who have hypoglossal nerve stimulation. Whereas those who had hypoglossal nerve stimulation actually had a greater improvement in their degree of sleepiness compared to positive airway pressure. And so I think we need more data in this space to help inform our decision-making with patients.

Michael Faulx, MD:
No, absolutely. I couldn't agree more. In summary, I think if you're a patient or a provider caring for patients who have disorders like difficult to treat hypertension, atrial fibrillation, particularly if the onset of the atrial fibrillation is at a younger than typical age, or if it's a very difficult to manage rhythm disorder, that these are the people that you should have a very high index of suspicion for obstructive sleep apnea. And if you're a patient, you can inquire about being tested. And if you're a provider, I think educating yourself about the STOP-BANG questionnaire and administering the questionnaire, it literally takes a minute of your time in a patient interview. A minute with a tape measure, because a lot of people don't often know their neck size. Men tend to, I find, because guys buy shirts based on their neck collar size. Women, sometimes you have to measure.

Michael Faulx, MD:
But I think you can very quickly ascertain those that are at moderate or high risk for having sleep apnea and refer them for appropriate testing. And if you strongly suspect obstructive sleep apnea in a patient that doesn't have a whole lot of other medical problems or any kind of physical disabilities or limitations, they can get a home sleep apnea test in a relatively timely fashion that can give you something to go on that moves you in the right direction.

Reena Mehra, MD, MS:
Absolutely. So building on that, I agree. I think in patients who we're highly suspecting obstructive sleep apnea, where there's high pre-test probability using a screening instrument such as the STOP-BANG, for instance, that's where home sleep apnea testing may be a reasonable option provided that there's not a lot of significant cardiac disease. And that's a bit open to interpretation, but if there's severe heart failure, cardiac dysfunction, then perhaps an in-lab study may serve you better because you can then see if there's a central component to the sleep apnea and not obstructive only. But if say there's cardiovascular risk, diabetes, hypertension, dyslipidemia, coronary disease, but otherwise not significant cardiac dysfunction, then home sleep apnea testing is a very reasonable place to start.

Reena Mehra, MD, MS:
And we know if there's high pre-test probability, despite the limitations of home sleep testing, we typically will pick up on that diagnosis of sleep apnea. But importantly, if you're suspecting that diagnosis of sleep apnea and you do the home sleep test and it is not indicative of sleep apnea, then I would still pursue in-lab testing because you're clinically suspecting that sleep apnea and the home test has limitations to the approach. So if you're clinically suspecting, then a negative home study, I would proceed with an in-lab study to really just ensure that there's absence of sleep apnea.

Michael Faulx, MD:
Any patient who has concerns about their heart disease and the presence or absence of underlying obstructive sleep apnea, I'd be happy to see you and I'm easy to find on the website.

Reena Mehra, MD, MS:
Yes. And it's wonderful to have colleagues like Dr. Faulx who are so engaged and great partners in identifying sleep apnea and then facilitating and routing them to our Sleep Disorders Center for further diagnostics and treatment. So that we really make sure that we're providing the best care for our patient in optimizing the treatment of those underlying sleep disorders to then mitigate and lessen any cardiovascular issues that may arise or negative cardiovascular outcomes.

Announcer:
Thank you for listening. We hope you enjoyed the podcast. We welcome your comments and feedback. Please contact us at [email protected]. Like what you heard? Subscribe wherever you get your podcasts or listen at clevelandclinic.org/cardiacconsultpodcast.

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Cardiac Consult

A Cleveland Clinic podcast exploring heart, vascular and thoracic topics of interest to healthcare providers: medical and surgical treatments, diagnostic testing, medical conditions, and research, technology and practice issues.

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