CLINICAL REVIEWSleep-disordered breathing and cardiovascular disease
Introduction
This paper is intended for clinicians. Its aim is to outline the cardiovascular risks associated with sleep-disordered breathing. The cellular and pathophysiologic mechanisms responsible for these relationships are beyond the scope of this paper, and are best left to other authors.1, 2, 3
Section snippets
Normal sleep and the heart
Normal sleep is a time of restoration for the heart, primarily because humans spend more time in nREM sleep than in REM sleep.4 NREM sleep is associated with increased parasympathetic activity, which reduces heart rate and blood pressure and increases cardiac electrical stability. REM sleep, on the other hand, is a time of increased sympathetic activity, which can increase blood pressure, heart rate, and arrhythmogenesis. As we enter Stage 1 nREM sleep, marked sinus arrhythmia can develop,
Sleep-disordered breathing and hypertension
The association between systemic hypertension and SDB has been known for decades; epidemiological studies suggest that approximately 40% of patients with systemic hypertension have sleep apnea and about 40% of sleep apnea patients have systemic hypertension. The approximations are partly due to the varied definitions of both sleep apnea and systemic hypertension. There is considerable inter-laboratory variation in the definitions and thresholds used for sleep apnea. Similarly, problems in
Cardiac arrhythmias
In normal sleep, reduced sympathetic activity results in reduced arrhythmogenicity as well as in slower heart rate and lowered blood pressure. Slow wave sleep is associated both with reduced sympathetic activity and with increased parasympathetic activity. Thus, SWS is typically a time of slow atrioventricular (AV) node conduction, lengthened cardiac refractory cycles, and of bradyarrhythmias. Both sinus arrhythmia and sinus bradycardia are normal in sleep, particularly during transitions
Congestive heart failure
Increased understanding of the pathophysiology of congestive heart failure (CHF) has led to the recognition that asymptomatic diastolic dysfunction often precedes the development of symptomatic CHF, and that many individuals are asymptomatic despite significant systolic left ventricular dysfunction (ejection fraction <40).30 It is likely that the increasing prevalence of SDB is contributing to the increasing prevalence of heart failure.
Sleep-disordered breathing is common in CHF. Data from the
Coronary artery disease
Case control studies demonstrated an association between sleep apnea and increased risk of myocardial infarction more than a decade ago.39, 40
In a group of 62 patients who had known coronary heart disease, those who had an RDI of >10 events/h were much more likely to experience cardiovascular death over a 5 year period than those who did not (37.5 vs. 9.3%), controlling for important risk factors such as age, weight and smoking.41 In a prospective 5 year follow-up of 408 patients with verified
Pulmonary hypertension
Assessing the relationship between sleep-disordered breathing and pulmonary artery hypertension (PH) is complicated by several factors. Among these is the fact that comorbid conditions such as chronic obstructive pulmonary disease and obesity frequently coexist in patients with SDB. The definition of PH used and the method of assessment, e.g. right heart catheterization vs. echocardiographic assessment also influences rates of diagnosis, as do the definitions and measurement techniques for
Stroke
Cerebrovascular events have been included as endpoints in several studies addressing the issue of sleep apnea and cardiovascular events.31, 42 In a recent and comprehensive review, Yaggi and Mohsenin51 conclude that SDB is a modifiable risk factor for stroke. An early study showed an astounding prevalence (80%) of sleep apnea in patients recovering from stroke.52 A case-control study of 24 patients with newly-diagnosed stroke showed that they had a 71% greater prevalence of PSG-confirmed sleep
Metabolic syndrome
The metabolic syndrome is a term used to describe a combination of abdominal obesity, elevated triglycerides, low high-density lipoprotein (HDL), hypertension, and hyperglycemia.61 This syndrome is a risk for cardiovascular disease, particularly hypertension. In addition to being a risk factor for cardiovascular disease, sleep apnea is also a risk factor for impaired glucose tolerance.62, 63 Clearly, many patients who have sleep apnea will also meet criteria for the Metabolic Syndrome, and vice
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2017, Journal of the American Society of HypertensionCitation Excerpt :A number of epidemiologic studies showed an association between OSA and HTN,8,9 particularly when nocturnal HTN is concerned.10 OSA is also associated with risk of cardiovascular events, congestive heart failure, atrial fibrillation, and stroke.11–13 Overnight polysomnography (PSG) is a gold standard in diagnosis of OSA.14
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The most important references are denoted by an asterisk.