Elsevier

Sleep Medicine Reviews

Volume 9, Issue 2, April 2005, Pages 131-140
Sleep Medicine Reviews

CLINICAL REVIEW
Sleep-disordered breathing and cardiovascular disease

https://doi.org/10.1016/j.smrv.2004.09.007Get rights and content

Summary

Untreated sleep apnea is a risk factor for hypertension, and CPAP treatment effects a blood pressure reduction comparable to that of pharmacologic monotherapy. Nevertheless, many current papers addressing the rapid increase in prevalence of hypertension and purporting to outline its management do not mention looking for or treating sleep apnea as a strategy. In addition to hypertension, virtually every adverse cardiovascular condition has been strongly associated with sleep disordered breathing in cross-sectional studies. There are also small prospective studies of the relationship between sleep-disordered breathing (SDB) and coronary heart disease and atrial fibrillation. Further, treatment studies show improvement or reduced risk of most cardiovascular sequelae of SDB with CPAP treatment. Beyond hypertension, which is well established, the strongest relationships between SDB and cardiovascular disease appear to be with congestive heart failure and bradyarrhythmias. Prospective studies are needed to confirm these relationships and to further delineate the risk.

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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