Stroke and Obstructive Sleep Apnea: A Review
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Obstructive sleep apnea (OSA) has been found to be an independent risk factor for stroke in large epidemiological studies. The mechanisms underlying this relationship have been investigated over the past 2–3 decades, with a particular focus on identifying pathophysiological pathways and risk modification strategies. Despite the advancements made, the specific understanding of the implicated mechanisms is still limited. This brief review focuses on presenting some of the epidemiological evidence of the linkage between OSA and stroke, discussing mechanistic pathways and the potential effect of OSA treatment in modulating the risk for stroke in these patients. Future directions for research in this field are also discussed.
KeywordsStroke Sleep apnea Obstructive sleep apnea Thrombosis Cardiovascular disease Cerebrovascular disease
Conflict of Interest
Daniel A. Barone declares that he has no conflicts of interest.
Ana C. Krieger declares that she has no conflicts of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
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- 6.•• Loke YK, Brown JW, Kwok CS, Niruban A, Myint PK. Association of obstructive sleep apnea with risk of serious cardiovascular events: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes. 2012;5(5):720–8. The authors present data from a meta-analysis of nine relevant prospective studies evaluating stroke and cardiovascular disease in sleep apnea. Their analysis demonstrated an overall odds ratio for incident stroke of 2.24 (1.57, 3.19 CI) among patients with sleep apnea. The risk was increased with worse severity of disease, as measured by the AHI.PubMedCrossRefGoogle Scholar
- 16.Fletcher EC. Cardiovascular effects of continuous positive airway pressure in obstructive sleep apnea. Sleep. 2000;15(23):S154–157.Google Scholar
- 19.Iber C. ea: The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications. 2007.Google Scholar
- 25.• Rice TB, Foster GD, Sanders MH, Unruh M, Reboussin D, Kuna ST, et al. The relationship between obstructive sleep apnea and self-reported stroke or coronary heart disease in overweight and obese adults with type 2 diabetes mellitus. Sleep. 2012;35(9):1293–8. This article reports data in 305 overweight or obese participants with type 2 diabetes evaluated by full polysomnography to determine the presence and severity of sleep apnea as part of an evaluation of the association of cardiovascular disease and stroke in this population. The study revealed that sleep apnea was associated with an increased odds ratio for stroke of 2.57 (1.03, 6.42 CI) after adjusting for confounding variables.PubMedGoogle Scholar
- 31.Somers VK, White DP, Amin R, Abraham WT, Costa F, Culebras A, et al. Sleep apnea and cardiovascular disease: an American Heart Association/American College of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council on Cardiovascular Nursing. J Am Coll Cardiol. 2008;52(8):686–717.PubMedCrossRefGoogle Scholar
- 32.•• Redline S, Yenokyan G, Gottlieb DJ, Shahar E, O'Connor GT, Resnick HE, et al. Obstructive sleep apnea-hypopnea and incident stroke: the sleep heart health study. Am J Respir Crit Care Med. 2010;18(2):269–77. The authors present the results of one of the largest epidemiological studies in sleep apnea, the Sleep Heart Health Study. A total of 5,422 subjects with full overnight polysomnography were prospectively followed for a period of 8.7 years. In men, an increased odds ratio for stroke was seen in association with an AHI above 20 events /h, at 2.86 (1.1, 7.4 CI). An incremental risk for stroke was seen in men for each unit of increase in AHI. In women, stroke risk was elevated in association with an AHI above 25.CrossRefGoogle Scholar
- 39.Medical Expenditure Panel Survey (MEPS) of the Agency for Healthcare Research and Quality (AHRQ). 2008.Google Scholar
- 53.Rossi VA, Stradling JR, Kohler M. Effects of obstructive sleep apnoea on heart rhythm. Eur Respir J. 2012;2012:20.Google Scholar
- 55.• Ciccone A, Proserpio P, Roccatagliata DV, Nichelatti M, Gigli GL, Parati G, et al. Wake-up stroke and TIA due to paradoxical embolism during long obstructive sleep apnoeas: a cross-sectional study. Thorax. 2013;68(1):97–104. This article evaluates the potential for paradoxical embolism as an etiology for stroke in OSA. The authors present a prospective evaluation of 335 patients with acute stroke or TIA, in which 21 % had evidence of prolonged apneic episodes and right-to-left shunt. The adjusted odds ratio for stroke or TIA upon waking was elevated in this subset at 1.91 (1.08, 3.38 CI).PubMedCrossRefGoogle Scholar
- 95.Parra-Ordaz O. The importance of treatment for breathing disorders during sleep in stroke patients. Rev Neurol. 2005;1(41):S35–37.Google Scholar
- 96.Martinez-Garcia MA, Soler-Cataluna JJ, Ejarque-Martinez L, Soriano Y, Roman-Sanchez P, Illa FB, et al. Continuous positive airway pressure treatment reduces mortality in patients with ischemic stroke and obstructive sleep apnea: a 5-year follow-up study. Am J Respir Crit Care Med. 2009;180(1):36–41.PubMedCrossRefGoogle Scholar