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Can Obstructive Sleep Apnea Cause Heart Failure

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Does Obstructive Sleep Apnea Cause Copd Or Vice Versa

Discussing Heart Failure and Obstructive Sleep Apnea | Dr. Ritankur Barkotoky

Obstructive sleep apnea and COPD often coexist. But there isnt a direct causal relationship.

OSA isnt caused by COPD. Instead, its caused by factors like enlarged tonsils and neuromuscular disorders.

Meanwhile, COPD is usually caused by chronic exposure to irritants. This includes substances like cigarette smoke, secondhand smoke, air pollution, and chemical fumes.

Having OSA doesnt mean youll develop COPD. Likewise, having COPD doesnt mean youll develop obstructive sleep apnea.

However, since both conditions involve airway inflammation, they often appear together. This is more likely if you smoke cigarettes, which is a risk factor for both diseases.

Overlap syndrome increases your chances of developing other health issues.

Sleep Apnea Cardiovascular Risk And Metabolism

Several studies have shown an association between sleep apnea and problems like type 2 diabetes , strokes , heart attacks and even a shortened lifespan, says Jun. Why this connection? For one thing, obesity is common in sleep apnea patients, and obesity greatly increases risks of diabetes, stroke and heart attack, he says. In most cases, obesity is the main culprit behind both conditions, Jun explains.

Still, its important to note that not everyone with sleep apnea is obese. Furthermore, evidence suggests an independent link between sleep apnea and diabetes. Our lab and others have shown that sleep apnea is associated with higher risks of diabetes, independent of obesity, and that sleep apnea can increase blood sugar levels, says Jun.

For people who are overweight or obese, weight loss is key for treating or avoiding sleep apnea. People who accumulate fat in the neck, tongue and upper belly are especially vulnerable to getting sleep apnea. This weight reduces the diameter of the throat and pushes against the lungs, contributing to airway collapse during sleep.

Women in particular should be careful as they age. While premenopausal women tend to put on weight in the hips and in the lower body instead of the belly, this shifts with time. Weight begins to accumulate in traditionally male areas like the tummy, and this leads to a greater chance of sleep apnea.

Pathophysiologic Consequences Of Sa

The mechanism by which sleep disordered breathing leads to adverse consequences is threefold: first, large negative intrathoracic pressure swings lead to increased transmural left and right ventricular pressures. This increase in afterload can cause atrial distension, arrhythmias, and pulmonary congestion. Larger negative intrathoracic pressure swings occur during obstructive apneas, but smaller swings occur during the hyperventilation that follows central apneas. Second, the apneas and hypopneas cause recurrent arousals which disrupt and fragment sleep leading to increased sympathetic activity, withdrawal of parasympathetic activity, and increased blood pressure and heart rate. Finally, the apneas and hypopneas result in oxygen desaturations and hypercapnia followed by a recovery period where reoxygenation and hypocapnia occur as ventilation increases. These fluctuations in arterial oxygen and carbon dioxide levels also contribute to sympathetic activation. Both alveolar hypoxia and hypercapnia may cause pulmonary arteriolar vasoconstriction, increased pulmonary artery pressures, increased right ventricular afterload, and eventually cor pulmonale. Recurrent cycles of hypoxia and re-oxygenation, via reactive oxygen species, result in redox gene activation and up-regulation of inflammatory cytokines culminating in endothelial cell dysfunction.

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Sleep Apnea And Cardiovascular Disease: Role Of Diabetes

The obesity pandemic over the last decade has accompanied a rise in the prevalence of type 2 diabetes mellitus. One of the characteristic features of diabetes mellitus is the inability to regulate serum glucose levels, resulting in impaired glucose tolerance affecting 11% to 15.6% of the U.S. population. Both type 1 and type 2 diabetes are associated with insulin deficiency, but type 2 diabetes is further complicated by cellular resistance to insulin action. According to data from the Third National Health and Nutrition Examination Survey, 5.1% of U.S. adults have an existing diagnosis for diabetes an additional 2.7% met criteria for the diagnosis, but have yet to receive one. Analysis from the same research group indicated that 15.6% of American adults exhibit glucose intolerance and 6.9% showed impaired fasting glucose levels .

Pulmonary Hypertension And Sleep Apnea

Is Sleep Apnea Hereditary? Symptoms &  Treatments

Pulmonary hypertension , historically categorized as either primary or secondary, is simply defined as a mean pulmonary artery pressure greater than 25 mmHg. Pressure estimates from echocardiography suggest that up to 20 % of the population may have PH, but most of this PH encompasses mild elevation in pulmonary artery pressures due to left ventricular disease . Because the historical classification of PH has proven insufficient to describe its broad range of etiologies, the World Health Organization proposed a reclassification of five broad categories and recognized SA as a cause of PH. In brief, the first category is PH that was classically known as pulmonary arterial hypertension , the second category is PH due to left heart disease, the third includes pulmonary diseases such as chronic obstructive pulmonary disease and SA, the fourth is chronic thromboembolic pulmonary hypertension, and the fifth a miscellaneous category which includes PH due to various disorders such as sarcoidosis. Discussion of these categories is beyond the scope of the present work here we focus on a discussion of the contribution of SA to PH.

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Gerd And Sleep Apnea: Which Causes The Other

Sleep apnea and gastroesophageal reflux disease are two conditions that appear unrelated. However, research shows a correlation between the two.

What Are Sleep Apnea and GERD?

Sleep apnea is a disorder that causes people to stop breathing during sleep. Obstructive sleep apnea , the most common type of apnea, occurs when the airway is blocked by soft tissue at the back of the throat. Many people who experience sleep apnea are unaware that their sleep cycle is interrupted throughout the night because they do not awaken completely. They usually complain of daytime sleepiness, headaches, forgetfulness and dry mouth.

About 60 percent of people with sleep apnea have chronic acid reflux, also known as gastroesophageal reflux disease . Acid reflux occurs when the lower esophageal sphincter remains open and gastric acid backflows into the esophagus. Common symptoms of GERD include heartburn, chest pain, a sour taste in the mouth and bad breath. However, it is possible to have GERD and not experience symptoms at all.

GERD Treatment Helps Remedy Sleep Apnea

Although researchers do not fully understand the relationship between sleep apnea and GERD, studies show that sleep disturbances may induce GERD and that untreated acid reflux impairs sleep. One study followed 48 adults who experienced GERD over three times per week. The men and women who had the most severe GERD symptoms also reported the worst sleep problems.

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Respiratory Sleep Disorders Contributing To Chf

OSA is the main RSD of concern in relation to cause of CHF. Research has provided the greatest understanding of its downstream cardiovascular effects.

Development of systemic hypertension as a precursor to CHF has been attributed to impaired baroreceptor control, impaired release of vasodilator endothelial nitric oxide and a generalized increase in sympathetic activity . Initially patients with OSA lose the usual nocturnal dip in systemic blood pressure and later they develop awaked hypertension and thereafter drug resistant hypertension . Thickening of the vascular media wall in the carotid arteries, whilst sparing the femoral arteries, has raised the possibility of snoring and vibrational damage to the endothelium .

Episodic atrial fibrillation is also common in patients with untreated OSA possibly related to surges in sympathetic activity whilst hypoxia and hypercapnia are present and the atrial walls are stretched. Atrial fibrillation is associated with ~25% reduction in cardiac output.

Coronary artery disease is not only more common in OSA patients, but it may be detected during polysomnography with ST depression on electrocardiograph . In patients with an established myocardial infarction, the relative risk of OSA is equivalent to a history of cigarette smoking .

Table 3

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Treating Sleep Apnea To Reduce The Risk Of Heart Disease

Talking to a doctor about sleep apnea is an important step that anyone can take to protect their heart health. If a person is diagnosed with sleep apnea, treatments are often effective. Treatment for sleep apnea depends on the type of sleep apnea detected and may include:

  • Lifestyle changes: Doctors may begin by informing patients about lifestyle changes that may reduce the severity of this condition. Weight loss, exercise, limiting alcohol, quitting smoking, and even changing your sleeping position may be helpful.
  • Positive airway pressure devices: PAP devices pump air through the airway, preventing the upper airway from collapsing during sleep.
  • Mouthpieces and oral appliances: Oral appliances reduce disordered breathing by changing the position of the jaw, tongue, or other part of the body thats constricting the airway.
  • Mouth and throat exercises: Depending on the cause of a persons sleep apnea, special exercises of the mouth and throat may help tone these muscles, making them less likely to interfere with breathing during sleep.
  • Surgery: Surgery for sleep apnea may involve changing parts of the body that cause airway constriction or implanting devices that causes tightening of the muscles around the airway.
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Sleep Apnoea In Heart Failure: To Treat Or Not To Treat

Preventive Cardiology: Sleep Apnea and Heart Disease

Department of Respiratory Medicine, Alfred Hospital, Melbourne, Victoria, Australia

Central Clinical School, Monash University, Melbourne, Victoria, Australia

Department of Respiratory Medicine, Alfred Hospital, Melbourne, Victoria, Australia

Central Clinical School, Monash University, Melbourne, Victoria, Australia

Department of Respiratory Medicine, Alfred Hospital, Melbourne, Victoria, Australia

Central Clinical School, Monash University, Melbourne, Victoria, Australia

Department of Respiratory Medicine, Alfred Hospital, Melbourne, Victoria, Australia

Central Clinical School, Monash University, Melbourne, Victoria, Australia

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What Is The Stop

The STOP-Bang Questionnaire is intended to give physicians an easy-to-use tool to identify people who might have obstructive sleep apnea. The questionnaire consists of eight yes-or-no questions based on the major risk factors for OSA. The name STOP-Bang is an acronym for the first letter of each symptom or physical attribute often associated with OSA:

  • Snoring: This question assesses whether or not you snore loudly enough to bother a bed partner.
  • Tiredness: This symptom involves feeling daytime tiredness, which may include falling asleep during daily tasks.
  • Observed Apnea: If a sleep partner has noticed that you stop breathing or gasp for air as you sleep, this can be a sign of OSA.
  • Pressure: High blood pressure is also a symptom.
  • BMI: Physicians look for a body mass index that is higher than 35.
  • Age: Those who are older than 50 are at higher risk for OSA.
  • Neck Circumference: Physicians measure your neck circumference. A measurement greater than 16 inches is considered a risk factor.
  • Gender: Males are considered to be more likely to have OSA.

Does Heart Rate Increase During An Apnea Event

Yes, its very possible for the heart rate to increase because of an apnea event. Theres a lot going on behind the scenes when apnea events happen besides just the oxygen levels maybe dippingand some people dont have a significant change in oxygen levels with their Obstructive sleep apnea

A sleep disorder that is marked by pauses in breathing of 10 seconds or more during sleep, and causes unrestful sleep.


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What Happens When You Stop Breathing

When you stop breathing, your heart rate also tends to drop the longer your body is deprived of oxygen. Then, your involuntary reflexes cause you to startle awake at the end of that period of not breathing. When this occurs, your heart rate tends to accelerate quickly and your blood pressure rises.

These are changes that take place acutely when you stop breathing. However, your body starts to experience chronic effects if you experience frequent apnea. Data suggests increased risk, particularly when you stop breathing roughly 30 times or more per hour. But there is likely a risk at even lower frequency rates.

For example, your blood pressure tends to go up, your heart walls thicken due to increased workload and the structure of your heart changes. It tends to become stiffer and less flexible because there are more fibrous cells growing in between the muscle cells.

All of those things increase the risk that you can have either atrial or ventricular arrhythmias. They also tend to reduce the function of the heart so that its less efficient at pumping blood.

Cpap In Patients With Heart Failure And Reduced Ejection Fraction

Avoid being snored to death

In a study of the effects of continuous positive airway pressure in 8 patients with OSA and HFrEF, oxygen desaturation, systolic BP, heart rate, and intrathoracic pressure decreased during stage 2 non-REM sleep. Nocturnal CPAP has also been shown to reduce central sympathetic vasoconstrictor outflow and improve vagal modulation of the heart by increasing high-frequency heart rate variability.

Investigators have conducted randomized clinical investigations , into the effects of nocturnal CPAP in patients with HFrEF and OSA. In a monthlong study of 24 patients, Kaneko and colleagues found significant reductions in AHI, number of arousals per night, and daytime systolic BP and heart rate in conjunction with a decrease in LV end-systolic diameter and an 8.8% absolute increase in LVEF on 2-dimensional echocardiograms. This study had no placebo group however, the same measurement in the untreated control group did not improve, which suggests that a sustained reduction in LV afterload secondary to CPAP therapy was the reason for improved LVEF in the treated group. This study included equal numbers of patients with ischemic and nonischemic cardiomyopathy.

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How Sleep Apnea Affects The Heart

Poor-quality sleep and heart disease are connected.

We’ve all heard stories about super snorers, whose snorts and snores rattle windows and awaken the neighbors. Many of these people suffer from sleep apnea. In this condition, the airway becomes blocked, or the muscles that control breathing stop moving. Either way, breathing stops… and then resumes with a gasp. In the worst cases, this can happen hundreds of times every night.

Because sleep apnea sufferers are constantly awakened, they have poor-quality sleep and feel exhausted all day. They may also suffer from poor cardiovascular health. The sleep disorder is found in 47% to 83% of people with cardiovascular disease, 35% of people with high blood pressure, and 12% to 53% of people with heart failure, atrial fibrillation , and stroke. Researchers estimate that untreated sleep apnea may raise the risk of dying from heart disease by up to five times.

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Heart Failure With Reduced Ejection Fraction

Many recent studies demonstrate a high prevalence of SDB in patients with HFREF. Our group performed a detailed systematic prospective study involving 100 ambulatory male veterans with stable, treated HF. One hundred and fourteen consecutive eligible patients were asked to take part in the study and 100 accepted. All had HFREF , and at the time of recruitment no questions were asked regarding symptoms or risk factors for SA. Further, each patient spent two nights in the sleep laboratory, the first night for habituation. Attended polysomonography was performed during the second night. Forty-nine percent of the subjects had SA as defined by a minimum AHI of 15, and 68% had SA using a threshold AHI of 5. Patients with OSA were obese and had habitual snoring and high blood pressure when compared to CSA patients who were thin and snored less. These findings have been substantiated by subsequent studies .

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The Dangers Of Uncontrolled Sleep Apnea

Youve probably heard that regular exercise and a heart-healthy diet arethe most important things you can do for your cardiovascular health. As itturns out, though, the quality of sleep you receive is also critical toyour hearts wellbeing.

In particular, undiagnosed sleep apnea is directly tied to an increased risk in cardiovascular and metabolic health. The scariest part? You might not even know you have this very common problem.

Sleep apnea happens when upper airway muscles relax during sleep and pinch off the airway, which prevents you from getting enough air. Your breathing may pause for 10 seconds or more at a time, until your reflexes kick in and you start breathing again, explains Jonathan Jun, M.D. , a pulmonary and sleep medicine specialist at the Johns Hopkins Sleep Disorders Center.

Sleep apnea occurs in about 3 percent of normal weight individuals but affects over 20 percent of obese people, Jun says. In general, sleep apnea affects men more than women. However, sleep apnea rates increase sharply in women after menopause. Sleep apnea is often linked to heart disease and metabolic issues like diabetes.

Normal Sleep Physiology And Cardiovascular System

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In order to understand how the negative pathophysiological consequences of SA may influence HF and PH, the effects of normal sleep architecture on nervous system activity should be understood. Sleep consists of two neurophysiologically distinct states: non-REM sleep occupies 80 % of total sleep time, and REM sleep accounts for the remaing 20 %. Non- REM sleep is divided into stages N1, N2, and N3. As sleep deepens from the lightest stage of sleep to the deepest stage , there is an orchestrated decrease in sympathetic activity and increase in parasympathetic activity. These autonomic changes have been demonstrated in several ways. Sympathetic outflow from the vascular bed, monitored by continuous peroneal nerve recordings, demonstrates progressive decrease from wakefulness through deep sleep. This is concomitant with decreased cerebrospinal fluid norepinephrine levels and a fall in plasma norepinephrine and epinephrine concentrations, indicating reduced sympatho-adrenal activity. As a result, arterial blood pressure progressively decreases as sleep deepens by approximately 1020 % relative to themean daytime arterial blood pressure. This phenomenon is known as dipping . Interestingly, normal dipping does not occur in SA , a phenomenon associated with increased mortality.

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