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Screening for Sleep Apnoea in Cardiac Rehabilitation

Screening for Sleep Apnoea in Cardiac Rehabilitation. Dr Frances WISE 1, 2 Mary-Anne BEER 1 Robyn SHEPPARD 1 CARDIAC REHABILITATION UNIT, CAULFIELD HOSPITAL, ALFRED HEALTH EPWORTH MONASH REHABILITATION MEDICINE UNIT. Obstructive Sleep Apnoea. Obstructive Sleep Apnoea.

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Screening for Sleep Apnoea in Cardiac Rehabilitation

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  1. Screening for Sleep Apnoea in Cardiac Rehabilitation Dr Frances WISE1, 2 Mary-Anne BEER1 Robyn SHEPPARD1 CARDIAC REHABILITATION UNIT, CAULFIELD HOSPITAL, ALFRED HEALTH EPWORTH MONASH REHABILITATION MEDICINE UNIT

  2. Obstructive Sleep Apnoea

  3. Obstructive Sleep Apnoea • A disorder in which breathing is repetitively interrupted during sleep due to collapse of the upper airway resulting in hypoxia and sleep fragmentation. • Sleep 1999

  4. Background • Obstructive Sleep Apnoea (OSA) affects 25% of men and 9% of womenin Australia • Snore Australia

  5. Background • Obstructive Sleep Apnoea is associated with significant chronic diseases

  6. The relationship with cardiac risk factors Prevalence of Obstructive Sleep Apnoea in Populations With Cardiovascular Disorders (CVD) Floras 2014

  7. Thus, not surprisingly, OSA is recognised as a predictor of premature cardiovascular death. • Floras 2014

  8. WHY - did we undertake this study? “Patients with untreated sleep apnoea may experience significantly worse outcomes during their cardiac rehab and recovery” Sharma Parker 2011 OSA is underdiagnosed and undertreated in Cardiac Rehabilitation patients

  9. HOW – did we perform this study? • 431cardiac rehabilitation patients completed: • the Berlin Sleep Questionnaire (BSQ), • We also measured: • Hospital Anxiety and Depression Scale • 6 Minute Walk Test (6MWT). • Body Mass Index (BMI), • Body Fat % and • Risk factor history

  10. HOW – did we perform this study? Berlin Sleep Questionnaire Netzer 1999

  11. HOW – did we perform this study? Berlin Sleep Questionnaire Score ≥ 2 on the BSQ = letter to GP to suggest FURTHER INVESTIGATION

  12. Next Steps? • The Berlin Sleep Questionnaire is only one screening tool that is freely available for screening for OSA.

  13. WHAT – were the results? • 38% (n = 164) of patients scored highly on BSQ & needed referral to a sleep clinic for follow up

  14. WHAT – were the results?Prevalence of Risk Factors in High Scorers

  15. WHAT – were the results? • Smoking is an independent risk factor for OSA • Smokers have a THREE fold increase in risk of developing OSA compared to non smokers • Prevalence of smoking in sleep apnoea patients may be as high as 35% • Kashyap 2001 • “Where there’s smoke, there’s sleep apnoea!”Krishnan et al 20

  16. WHAT – were the results? Prevalence of Risk Factors in High Scorers

  17. WHAT – were the results? • Hypertension is a key risk factor for CVD • In the medical literature a third or more of individuals with hypertension also will have OSA .Floras 2015

  18. WHAT – were the results?Prevalence of Risk Factors in High Scorers

  19. WHAT – were the results? • Intermittent hypoxia and sleep fragmentation can lead to insulin resistance • Hamilton Naughton 2013 • Large published studies indicate that OSA is a predictor of diabetes, with OSA patients 30% more likely to develop diabetes. • Kendzerska et al 2014 • Patients with diabetes have an increased risk of developing OSA • Hamilton Naughton 2013

  20. WHAT – were the results?Prevalence of Risk Factors in High Scorers

  21. WHAT – were the results? • The external and internal neck circumferences and the degree of obesity are important predictors of sleep apnoeaKatz 1989 • In general, the physical examination is normal in patients with OSA, aside from the presence of obesity (body mass index: >30 kg/m2), an enlarged neck circumference (men: >43 cm [17 in]; women: >37 cm [15 in]). • Downey 2018

  22. WHAT – were the results?Prevalence of Risk Factors in High Scorers

  23. WHAT – were the results? • Obesity is a major risk factor for both cardiovascular disease and OSA • Wong et al 2018 • A 10% weight gain can lead to a SIX fold increase in the chances of developing OSA • Peppard Young Palta 2000

  24. WHAT – were the results?Prevalence of Risk Factors in High Scorers

  25. WHAT – were the results? • Sleep disturbance is strongly associated with depressive symptoms and health related quality of life • Banack2014 • Patients with both depression and OSA have an increased risk of death/adverse events following myocardial infarction, more than either depression or OSA alone. • Hayanoet al 2012

  26. WHAT – were the results?Prevalence of Risk Factors in High Scorers

  27. WHAT – were the results? • Health related quality of life influences both compliance with medical treatments and program adherence • Banack2014 • OSA is associated with impaired exercise capacity and lower peak VO2. • Beitleret al 2014

  28. WHAT – were the results?Prevalence of Risk Factors in High Scorers

  29. WHAT – were the results? • To Summarise: • HIGH SCORERS: • Were significantly more likely to have a history of smoking, hypertension or diabetes. • Had Higher BMI, body fat % and neck circumference higher prevalence of depression and anxiety. • Had Lower Exercise Tolerance and there was less improvement in 6MWT by discharge.

  30. WHAT – were the results? Of our 164 high scorers, only 5patients were referred by their GPs for further investigation.

  31. Next Steps? Our Unit is developing a protocol to initiate direct referral to sleep clinics, with examination of outcomes including Quality of Life, fat mass and mood.

  32. THANK YOU!

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