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Clinical year in review

Clinical year in review. Sleep disorders Antalya, April 26, 2007 Prof. J. Verbraecken Antwerp University Hospital Belgium. Johan.verbraecken@uza.be. Clinical year in review: sleep disorders Introduction.

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Clinical year in review

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  1. Clinical year in review Sleep disorders Antalya, April 26, 2007 Prof. J. Verbraecken Antwerp University Hospital Belgium Johan.verbraecken@uza.be

  2. Clinical year in review: sleep disordersIntroduction • The most important developments in respiratory sleep medicine last year relate to the interaction between the respiratory and cardiovascular systems in patients with SRBD. • CV complications of obstructive sleep apnoea syndrome (OSAS): prevalence and mechanisms • Congestive heart failure with sleep apnea • Impact of CPAP therapy on CV outcomes • Pathogenesis of OSA • Diagnosis of OSA • Treatment of OSA

  3. CV complications of OSA • CV disease represents the principal physical morbidity and probable mortality from OSAS. • Hypertension • Ischaemic heart disease • Cerebrovascular disease • The precise mechanisms are unclear but are likely to be multifactorial • Pathophysiologic, neurologic and cell/molecular mechanisms likely play a role.

  4. CV complications (and alterations) of OSARight ventricular function Shivalkar B et al JACC 2006; 47(7): 1433-9

  5. CV complications (and alterations) in OSARight ventricular function Shivalkar B et al JACC 2006; 47(7): 1433-9

  6. CV complications (and alterations) in OSARV:Effect of CPAP Shivalkar B et al JACC 2006; 47(7): 1433-9

  7. CV complications (and alterations) in OSAAHT: effect of CPAP Robinson GV et al Eur Respir J 2006; 27:1229-1235 35 nonsleepy, hypertensive OSA

  8. CV complications (and alterations) in OSAAHT: effect of CPAP Robinson GV et al Eur Respir J 2006; 27:1229-1235 Therapeutic vs sham-placebo CPAP

  9. CV complications (and alterations) in OSACAD Peker Y et al Eur Respir J 2006:28: 596-602 Sleep clinic Cohort without concomitant heart disease at inclusion in 1991 8 years follow-up; n=308

  10. Peker Y et al Eur Respir J 2006:28: 596-602 Incidence of CAD at follow-up

  11. OSA !! Risk x 6 Non OSA Peker Y et al Eur Respir J 2006:28: 596-602 Predictors of CAD: time since baseline; current age; SaO2 min; asthma/COPD at baseline; efficient OSA treatment (inverse effect)

  12. Impact of CPAP Peker Y et al Eur Respir J 2006:28: 596-602

  13. CV complications (and alterations) in OSAAMI Tsukamoto K et al Circ J 2006;70:1553-1556

  14. CV complications (and alterations) in OSAIncident AF Gami AS et al JACC 2007;49(5):565-571

  15. CV complications (and alterations) in OSAIncident AF Gami AS et al JACC 2007;49(5):565-571

  16. CV complications (and alterations) in OSAIncident AF Gami AS et al JACC 2007;49(5):565-571

  17. Congestive Heart Failure with sleep apneaImpact on sleep quality Hastings PC et al Eur Respir J 2006;27:745-755

  18. Congestive Heart Failure with sleep apnea TIB SL SEI Daytime activity Hastings PC et al Eur Respir J 2006;27:745-755

  19. Congestive Heart Failure with sleep apneaUse of acetazolamide Javaheri S. AJRCCM 2006; 173: 234-7

  20. Congestive Heart Failure with sleep apneaUse of acetazolamide Javaheri S. AJRCCM 2006; 173: 234-7

  21. Complex sleep apnea syndrome (CompSAS) • Definition: a group of patients with OSAS who develop a high frequency of central apneas and/or a disruptive Cheyne-Stokes respiration (CSR) pattern after application of CPAP • Complexitiy which may not be unmasked until application of CPAP • Prevalence: 34 on 223 (15%) • Predominantly male patients • Low OAI during CPAP • Fairly similar patients respond differently to CPAP • No clinical differences with OSA or CSA • Trend towards longer apnea duration in the patients with CompSAS • Hypothesis: More instability in respiratory and/or cardiovascular control at baseline than patients with OSA Morgenthaler TI et al Sleep 2006,29(6):1203-1209

  22. Management of Complex sleep apnea • CPAP not effective • BIPAP ? • ASV ?: at least worthwhile to evaluate Sleep Medicine 2006;7:474-479

  23. Pathogenesis OSA and diabetes V. Viot-Blanc, P. Levy. Sleep Medicine 2006:538-540

  24. N=938 men (general practice databases) • Definition OSA: ODI>10 • 23% had OSA ! • Confirmed by PSG West SD et al, Thorax 2006;61:945-950

  25. Veasey S et al Sleep 2006; 29(3):280-281

  26. Increased levels of AGE in nondiabetic OSA Tan K et al Sleep 2006;29(3):329-333

  27. Pathogenesis OSA and antioxidants Barcelo A et al Eur Respir J 2006;27:756-760

  28. Pathogenesis: OSA and antioxidants Barcelo A et al Eur Respir J 2006;27:756-760

  29. Antioxidants and HCVR: harmfull ? Zakynthinos S et al AJRCCM 2007;175:62-68 HCVR 1.70.4  3.2 0.5 l/min/mmHg 200 mg Vit E; 50.000 IU Vit A; 1g Vit C; 600 mg allopurinol; 2 g NAC

  30. Pathogenesis: OSA and antioxidantsImpact of Vit C: beneficial ? Beneficial effect of Vit C in OSA group ? Vit C and FM vasodilation Grebe M et al AJRCCM 2006;173:897-901

  31. Solh AA et al ERJ 2006;27:997-1002 N=12 2 w 300 mg allopurinol compared to placebo Less oxidative stress and increase in FMD

  32. Pathogenesis: OSA and antioxidantsImpact of CPAP = Barcelo A et al Eur Respir J 2006;27:756-760

  33. Pathogenesis: sleep apnea and pre-eclampsia Yinon D et al ERJ 2006;27:328-333

  34. Pathogenesis: Intraocular pressure before and during CPAP Kiekens S et al, IOVS

  35. Descent from mountains to sea level : AHI 53 4733 mmHg In some even normalisation of AHI Chest 2006;130:1744-50

  36. Diagnosis: Functional imaging of the UA Computational Fluid Dynamics in OSA Conversion of a CT scan of the UA into a CAD model Creation patient specific 3D-computer model Grid of the upper airway Visualisation of flow contours  resistance can be calculated

  37. Diagnosis: Functional imaging of the UA Computational Fluid Dynamics in OSA • Sung SJ et al. Angle Orthod 2006;76:791-9 • Vos W et al J Biomech 2007, in press.

  38. Diagnosis: Development of single channel portable SDB diagnostic device Certain commercially available pacemakers have a trans-thoracic impedance sensor primarily intended to adjust pacing rate during exercise upon changes in minute ventilation Pace 2006;29:1036-43

  39. Diagnosis: development of single channel portable SDB diagnostic device Pace 2006;29:1036-43

  40. Diagnosis: CPAP treatment trial over 2 W as an initial diagnostic test in comparison with PSG • Prediction of OSA: sensitivity 80%, specificity 97%, PPV 97%, NPV 78% • PSG could be avoided in 46% of the patients Senn O et al, Chest 2006;129:67-75

  41. Treatment: CPAP Compliance Addition of hypnotics ? Bradshaw DA et al Chest 2006;130:1369-1376 N=72 Hypnotic vs placebo vs standard care

  42. Treatment: CPAP Compliance Addition of hypnotics ? Bradshaw DA et al Chest 2006;130:1369-1376

  43. Treatment: Long-term CPAP compliance Sucena M et al Eur Respir J 2006;27:761-766

  44. Treatment: Long-term CPAP compliance 6h40min 5h20min Sucena M et al Eur Respir J 2006;27:761-766

  45. Treatment When do patients interrupt CPAP therapy ? Sucena M et al Eur Respir J 2006;27:761-766

  46. Treatment: UPPP • N=110 patients • 82% discharged on the day of surgery • Admission: due to pain and nausea • UPPP can be carried safely on an outpatient basis. Otolaryngol Head and Neck Surgery 2006, 134:542-544

  47. Treatment: overdrive pacing • Using a pacemaker night heart-rate feature that allows programming of heart rates separately during the night and day • NOP followed by a reduction in circulation time did not improve AHI in patients with OSA. • 1 week: Melzer C et al, Sleep 2006;29(9):1197-1202 • 1 night: Krahn AD et al, J Am Coll Cardiol 2006;47:379-83

  48. Sleep: Impact of sleep quality and quantity Gangwisch JE et al Sleep 2005;28(10):1289-1296 Gangwisch JE et al Hypertension 2006;47:833-839 N=4810 patients. Sleep durations of <5h per night were associated with a significantly increased risk of hypertension (HR 2.1) in subjects between the ages of 32 and 59 years, signficant after controlling for obesity and diabetes

  49. 2813 men, 3097 female • Usual sleep duration above or below the median of 7 to 8 hours per night is associated with an increased prevalence of hypertension, particularly at the extreme of less than 6 hours per night. Gottlieb D et al, Sleep 2006, 29(8):1009-14

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