Managing Hypertension through the Patient Centered Medical Home

1. Managing Hypertension through the Patient Centered Medical Home Web Conference Series 12 – 1 p.m., June 17, 2009 Hypertension & Obstructive Sleep Apnea Jacalyn A. Nelson, MD, Dean Health System Sponsored by:

2. Agenda • Obstructive sleep apnea • Hypertension • Patient Centered Medical Home

3. Definitions • Obstructive Apnea • Cessation of airflow at least ten seconds in duration • With or without an oxygen desaturation or arousal • Central Apnea • No airflow • No effort to breathe • At least ten seconds in duration • Hypopnea • No universally accepted definition • Commonly – a 30% or greater airflow reduction accompanied by a 3% to 4% oxygen desaturation and arousal • At least ten seconds in duration

4. Definitions • RERA (Respiratory Effort-Related Arousal) • Increased respiratory effort leading to an arousal • Does not meet the criteria for apnea or hypopnea • At least ten seconds in duration

5. Definitions • Apnea/Hypopnea Index (AHI) • The number of apneas plus hypopneas per hour of sleep • Respiratory Disturbance Index (RDI) • The AHI plus RERAs per hour of sleep • Obstructive Sleep Apnea • RDI (or sometimes AHI) ≥ 5

6. Anatomy • Pharyngeal Airway Patency • Balance between upper airway muscles and intraluminal pressure

7. Craniofacial Abnormalities • Low-lying Soft Palate • Elongated or Widened Uvula • Tonsillar Hypertrophy • Macroglossia • Micrognathia • Retrognathia • Nasal Pathology • Deviated Septum • Turbinate Hypertrophy

8. Craniofacial Abnormalities • Low-lying Soft Palate • Elongated or Widened Uvula • Tonsillar Hypertrophy • Macroglossia • Micrognathia • Retrognathia • Nasal Pathology • Deviated Septum • Turbinate Hypertrophy

9. Common Presenting Symptoms - Daytime • Somnolence and/or fatigue • Napping • Drowsiness during daytime activities • Falling asleep at the wheel • Nodding off during meetings • High caffeine intake • Impaired memory and concentration • Irritability • Morning headaches

10. Common Presenting Symptoms - Nocturnal • Loud snoring • Witnessed apneas • Respiratory disturbances • Sleep maintenance difficulties • Diaphoresis • Sensation of choking or dyspnea • Nocturnal reflux • Nocturia

11. Risk Factors • Obesity • BMI > 25 • Android-type fat deposition • Age • > 65 • Craniofacial Abnormalities • Behavioral Factors • Alcohol and Sedatives • Smoking

12. Risk Factors • Genetic Influences • Positive family history • African-American, Asian, Hispanic ethnicity • Associated Medical Conditions • Trisomy 21 • Achondroplasia • Arnold-Chiari • Klippel-Feil • Pierre Robin • Marfan’s Syndrome • Hypothyroidism

13. Diagnosis • Quick Assessment Tool • Epworth Sleepiness Scale (Sleep, 1999) • Validated tool • Overnight Polysomnography

14. Epworth Sleepiness Scale (ESS) Use the following scale to choose the most appropriate number for each situation: 0 = would never doze or sleep 1 = slight chance of dozing or sleeping 2 = moderate chance of dozing or sleeping 3 = high chance of dozing or sleeping Situation Chance of Dozing or Sleeping Sitting and reading _____ Watching TV _____ Sitting inactive in a public place _____ Being a passenger in a motor vehicle for an hour or more _____ Lying down in the afternoon _____ Sitting and talking to someone _____ Sitting quietly after lunch (no alcohol) _____ Stopped for a few minutes in traffic while driving _____ Total Score (add up all scores) _____

15. Adverse Associations • Causes hypertension • Associated with • Stroke • Myocardial infarction • Sudden death at night • Right-sided heart failure • Cor pulmonale • Atrial fibrillation • Diabetes mellitus • Depression

17. Epidemiology of Sleep Apnea • Current prevalence data inaccurate • Wisconsin Sleep Cohort Study (1993) • AHI > 5 • 2% of women • 4% of men • Sleep Heart Health Study (1997) • RDI > 15 • In this study, RDI = AHI • 22% of 1824 people

18. Epidemiology of Sleep Apnea & Hypertension • 45% of patients with hypertension have sleep apnea • 80% of patients with drug resistant hypertension have sleep apnea

19. Pathophysiology of Sleep Apnea & Hypertension • Sympathetic activation is probably causal • Increased hypoxia and hypercapnea act through chemoreflexes to activate the sympathetic nervous system and vasoconstriction • When breathing resumes, there is an inspiratory increase in ventricular filling leading to increase in stroke volume • Vagolytic effects of inspiration cause tachycardia • Increased stroke volume and heart rate lead to increased cardiac output which enters vasoconstricted circulation (Fletcher, J Sleep Res, 1995)

20. Pathophysiology of Sleep Apnea & Hypertension • Other candidate mechanisms include: • Modification of the cardiovascular system in response to the large change in intra-thoracic pressure (Ehlenz, J Sleep Res, 1995) • Increased stress from sleep disruption (Guilleminault, J Sleep Res, 1995) • Endothelial dysfunction (Ip, Am J Respir Cri Care Med, 2004)

21. Treatment • CPAP is the most efficacious treatment for sleep apnea • CPAP may lower blood pressure • Approximate 10 mmHg drop in systolic and diastolic BP (Becker, et al., 2003)

22. Composite Patient • 55 year old female w/ CC of snoring, restless sleep, fatigue and daytime sleepiness • Started antidepressants three years ago • Has gained 20 pounds • Past medical history • Impaired glucose • Depression • Hypothyroidism

23. Composite Patient • Exam • BP 136/82 • Weight 170 pounds on a 5’5” frame • Oropharyngeal exam • Low-lying palate • Mild retrognathia • Otherwise unremarkable • Sleep schedule • Bedtime 10:30 or 11 PM • Wake time 5:30 AM • Awakening three to four times per night • Has difficulty getting back to sleep one to two times per week • ESS = 12

24. Composite Patient • Polysomnography • RDI = 18 • Low oxygen saturation = 83% • CPAP titration • Titrated to 9 cmH2O • Patient returns to clinic • Feeling better • BP 126/78

25. Conclusion • Sleep apnea is fairly common • Large impact on overall health • Causal role in the development of hypertension • Compelling evidence that treating sleep apnea lowers blood pressure • Patient Centered Medical Home • Identifying sleep apnea in patients • Monitoring CPAP compliance

26. Patient Centered Medical Home Overview • In a Patient Centered Medical Home: • Patients have a relationship with a personal physician. • A practice-based care team takes collective responsibility for the patient’s ongoing care. • The care team is responsible for providing or arranging all the patient’s health care needs. • The results are: • Better health outcomes • Lower costs • Greater equity in health

27. 12 Components of the Patient Centered Medical Home •  After Hours Coverage •  Chronic Care Model •  Disease Registry •  Electronic Health Records •  Email with Patients • E-Prescribing •  Evidence-Based Clinical Guidelines •  Group Visits •  Office Redesign •  Open Access Scheduling • Quality Outcomes Measurements •  Team Approach

29. Hypertension & Obstructive Sleep Apnea Managing Hypertension through the Patient Centered Medical Home CME Credit This activity has been reviewed and is acceptable for up to 1 Prescribed credit by the American Academy of Family Physicians. To receive CME credit you must complete the pre- and post-test. The link for the post-test will be sent to your email address following the webinar. If you do not receive the link by June 20, please contact Wisconsin Academy of Family Physicians Project Coordinator Sheri Urban at 262/512-0606 or email academy@wafp.org.

30. Thank you for joining us for Hypertension & Obstructive Sleep Apnea. The next presentation in the series will be: Hypertension & Chronic Kidney Disease Paul S. Kellerman, MD, FACP 12-1 p.m., July 16, 2009 Explore the relationship between hypertension and chronic kidney disease with Paul S. Kellerman, MD, FACP, an Associate Professor of Medicine in the UW School of Medicine and Public Health Nephrology Division, the Director of ESRD and the Director of the UW Hypertension Clinic. Managing Hypertension through the Patient Centered Medical Home For more information on the Patient Centered Medical Home in Wisconsin, visit www.wafp.org/pcmh. Thank you to Fred Petillo, Julie Shinefield, Cindy Huber and David Eitrheim, MD for their assistance in developing the webinar series.