Obstructive Sleep Apnea and Cardiovascular Disease

Prevention

Opinion statement

Obstructive sleep apnea is a highly prevalent disease that often goes undetected for many years before diagnosis. Although most patients seek treatment to improve symptoms of daytime sleepiness, a growing body of literature suggests that treatment may also modulate cardiovascular risk. This article summarizes the current literature regarding the associations between sleep-disordered breathing and adverse cardiovascular outcomes and reviews the lesser body of data demonstrating the cardiovascular benefits of therapy.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Young T, Palta M, Dempsey J, et al.: The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993, 328(17):1230–1235.CrossRefPubMedGoogle Scholar
  2. 2.
    Wright J, Johns R, Watt I, et al.: Health effects of obstructive sleep apnoea and the effectiveness of continuous positive airways pressure: a systematic review of the research evidence. BMJ 1997, 314(7084):851–860.PubMedGoogle Scholar
  3. 3.
    Young T, Peppard PE, Gottlieb DJ: Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med 2002, 165(9):1217–1239.CrossRefPubMedGoogle Scholar
  4. 4.
    Nieto FJ, Young TB, Lind BK, et al.: Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study JAMA 2000, 283(14):1829–1836.Google Scholar
  5. 5.
    Peker Y, Carlson J, Hedner J: Increased incidence of coronary artery disease in sleep apnoea: a long-term follow-up. Eur Respir J 2006, 28(3):596–602.CrossRefPubMedGoogle Scholar
  6. 6.
    Gami AS, Hodge DO, Herges RM, et al.: Obstructive sleep apnea, obesity, and the risk of incident atrial fibrillation. J Am Coll Cardiol 2007, 49(5):565–571.CrossRefPubMedGoogle Scholar
  7. 7.
    Mehra R, Benjamin EJ, Shahar E, et al.: Association of nocturnal arrhythmias with sleep-disordered breathing: the Sleep Heart Health Study. Am J Respir Crit Care Med 2006, 173(8):910–916.CrossRefPubMedGoogle Scholar
  8. 8.
    Arzt M, Young T, Finn L, et al.: Association of sleep-disordered breathing and the occurrence of stroke. Am J Respir Crit Care Med 2005, 172(11):1447–1451.CrossRefPubMedGoogle Scholar
  9. 9.
    Kasai T, Narui K, Dohi T, et al.: Prognosis of patients with heart failure and obstructive sleep apnea treated with continuous positive airway pressure. Chest 2008, 133(3):690–696.CrossRefPubMedGoogle Scholar
  10. 10.
    Marin JM, Carrizo SJ, Vicente E, Agusti AG: Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet 2005, 365(9464):1046–1053.PubMedGoogle Scholar
  11. 11.•
    Young T, Finn L, Peppard PE, et al.: Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin sleep cohort. Sleep 2008, 31(8):1071–1078.PubMedGoogle Scholar
  12. 12.
    Marshall NS, Wong KK, Liu PY, et al.: Sleep apnea as an independent risk factor for all-cause mortality: the Busselton Health Study. Sleep 2008, 31(8):1079–1085.PubMedGoogle Scholar
  13. 13.
    Bixler EO, Vgontzas AN, Lin HM, et al.: Association of hypertension and sleep-disordered breathing. Arch Intern Med 2000, 160(15):2289–2295.CrossRefPubMedGoogle Scholar
  14. 14.
    Peppard PE, Young T, Palta M, Skatrud J: Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med 2000, 342(19):1378–1384.CrossRefPubMedGoogle Scholar
  15. 15.
    Logan AG, Tkacova R, Perlikowski SM, et al.: Refractory hypertension and sleep apnoea: effect of CPAP on blood pressure and baroreflex. Eur Respir J 2003, 21(2):241–247.CrossRefPubMedGoogle Scholar
  16. 16.
    Alajmi M, Mulgrew AT, Fox J, et al.: Impact of continuous positive airway pressure therapy on blood pressure in patients with obstructive sleep apnea hypopnea: a meta-analysis of randomized controlled trials. Lung 2007, 185(2):67–72.CrossRefPubMedGoogle Scholar
  17. 17.
    Haentjens P, Van Meerhaeghe A, Moscariello A, et al.: The impact of continuous positive airway pressure on blood pressure in patients with obstructive sleep apnea syndrome: evidence from a meta-analysis of placebo-controlled randomized trials. Arch Intern Med 2007, 167(8):757–764.CrossRefPubMedGoogle Scholar
  18. 18.
    Lenfant C: Do sleep disorders have an impact on blood pressure? Am J Ther 2008, 15(4):345–350.CrossRefPubMedGoogle Scholar
  19. 19.
    Young T, Peppard PE, Taheri S: Excess weight and sleep-disordered breathing. J Appl Physiol 2005, 99(4):1592–1599.CrossRefPubMedGoogle Scholar
  20. 20.
    O’Connor GT, Caffo B, Newman AB, et al.: Prospective study of sleep-disordered breathing and hypertension: the Sleep Heart Health Study. Am J Respir Crit Care Med 2009, 179(12):1159–1164.CrossRefPubMedGoogle Scholar
  21. 21.
    Somers VK, Dyken ME, Clary MP, Abboud FM: Sympathetic neural mechanisms in obstructive sleep apnea. J Clin Invest 1995, 96(4):1897–1904.CrossRefPubMedGoogle Scholar
  22. 22.
    Hla KM, Young T, Finn L, et al.: Longitudinal association of sleep-disordered breathing and nondipping of nocturnal blood pressure in the Wisconsin Sleep Cohort Study. Sleep 2008, 31(6):795–800.PubMedGoogle Scholar
  23. 23.
    Kato M, Roberts-Thomson P, Phillips BG, et al.: Impairment of endothelium-dependent vasodilation of resistance vessels in patients with obstructive sleep apnea. Circulation 2000, 102(21):2607–2610.PubMedGoogle Scholar
  24. 24.
    Schafer H, Koehler U, Ploch T, Peter JH: Sleep-related myocardial ischemia and sleep structure in patients with obstructive sleep apnea and coronary heart disease. Chest 1997, 111(2):387–393.CrossRefPubMedGoogle Scholar
  25. 25.
    Punjabi NM, Caffo BS, Goodwin JL, et al.: Sleep-disordered breathing and mortality: a prospective cohort study. PLoS Med 2009, 6(8):e1000132.CrossRefPubMedGoogle Scholar
  26. 26.
    Sahlin C, Sandberg O, Gustafson Y, et al.: Obstructive sleep apnea is a risk factor for death in patients with stroke: a 10-year follow-up. Arch Intern Med 2008, 168(3):297–301.CrossRefPubMedGoogle Scholar
  27. 27.
    Peker Y, Kraiczi H, Hedner J, et al.: An independent association between obstructive sleep apnoea and coronary artery disease. Eur Respir J 1999, 14(1):179–184.CrossRefPubMedGoogle Scholar
  28. 28.
    Shah NA, Yaggi HK, Concato J, Mohsenin V: Obstructive sleep apnea as a risk factor for coronary events or cardiovascular death. Sleep Breath 2009 Sep 24 (Epub ahead of print).Google Scholar
  29. 29.
    Gami AS, Howard DE, Olson EJ, Somers VK: Day-night pattern of sudden death in obstructive sleep apnea. N Engl J Med 2005, 352(12):1206–1214.CrossRefPubMedGoogle Scholar
  30. 30.
    Shahar E, Whitney CW, Redline S, et al.: Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med 2001, 163(1):19–25.PubMedGoogle Scholar
  31. 31.
    Valham F, Mooe T, Rabben T, et al.: Increased risk of stroke in patients with coronary artery disease and sleep apnea: a 10-year follow-up. Circulation 2008, 118(9):955–960.CrossRefPubMedGoogle Scholar
  32. 32.
    Mooe T, Franklin KA, Holmstrom K, et al.: Sleep-disordered breathing and coronary artery disease: long-term prognosis. Am J Respir Crit Care Med 2001, 164(10 Pt 1):1910–1913.PubMedGoogle Scholar
  33. 33.
    Yaggi HK, Concato J, Kernan WN, et al.: Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med 2005, 353(19):2034–2041.CrossRefPubMedGoogle Scholar
  34. 34.
    Bassetti CL, Milanova M, Gugger M: Sleep-disordered breathing and acute ischemic stroke: diagnosis, risk factors, treatment, evolution, and long-term clinical outcome. Stroke 2006, 37(4):967–972.CrossRefPubMedGoogle Scholar
  35. 35.
    Parra O, Arboix A, Bechich S, et al.: Time course of sleep-related breathing disorders in first-ever stroke or transient ischemic attack. Am J Respir Crit Care Med 2000, 161(2 Pt 1):375–380.PubMedGoogle Scholar
  36. 36.
    Netzer N, Werner P, Jochums I, et al.: Blood flow of the middle cerebral artery with sleep-disordered breathing: correlation with obstructive hypopneas. Stroke 1998, 29(1):87–93.PubMedGoogle Scholar
  37. 37.
    Shamsuzzaman AS, Winnicki M, Lanfranchi P, et al.: Elevated C-reactive protein in patients with obstructive sleep apnea. Circulation 2002, 105(21):2462–2464.CrossRefPubMedGoogle Scholar
  38. 38.
    Sanner BM, Konermann M, Tepel M, et al.: Platelet function in patients with obstructive sleep apnoea syndrome. Eur Respir J 2000, 16(4):648–652.CrossRefPubMedGoogle Scholar
  39. 39.
    Oga T, Chin K, Tabuchi A, et al.: Effects of obstructive sleep apnea with intermittent hypoxia on platelet aggregability. J Atheroscler Thromb 2009, 16(6):862–869.PubMedGoogle Scholar
  40. 40.
    Ziegler MG, Nelesen R, Mills P, et al.: Sleep apnea, norepinephrine-release rate, and daytime hypertension. Sleep 1997, 20(3):224–231.PubMedGoogle Scholar
  41. 41.
    Larsson PT, Wallen NH, Egberg N, Hjemdahl P: Alpha-adrenoceptor blockade by phentolamine inhibits adrenaline-induced platelet activation in vivo without affecting resting measurements. Clin Sci (Lond) 1992, 82(4):369–376.Google Scholar
  42. 42.
    Reinhart WH, Oswald J, Walter R, Kuhn M: Blood viscosity and platelet function in patients with obstructive sleep apnea syndrome treated with nasal continuous positive airway pressure. Clin Hemorheol Microcirc 2002, 27(3–4):201–207.PubMedGoogle Scholar
  43. 43.
    Chin K, Ohi M, Kita H, et al.: Effects of NCPAP therapy on fibrinogen levels in obstructive sleep apnea syndrome. Am J Respir Crit Care Med 1996, 153(6 Pt 1):1972–1976.PubMedGoogle Scholar
  44. 44.•
    Savransky V, Nanayakkara A, Li J, et al.: Chronic intermittent hypoxia induces atherosclerosis. Am J Respir Crit Care Med 2007, 175(12):1290–1297.CrossRefPubMedGoogle Scholar
  45. 45.
    Ohga E, Nagase T, Tomita T, et al.: Increased levels of circulating ICAM-1, VCAM-1, and L-selectin in obstructive sleep apnea syndrome. J Appl Physiol 1999, 87(1):10–14.PubMedGoogle Scholar
  46. 46.
    Dyugovskaya L, Polyakov A, Lavie P, Lavie L: Delayed neutrophil apoptosis in patients with sleep apnea. Am J Respir Crit Care Med 2008, 177(5):544–554.CrossRefPubMedGoogle Scholar
  47. 47.
    Ip MS, Lam B, Ng MM, et al.: Obstructive sleep apnea is independently associated with insulin resistance. Am J Respir Crit Care Med 2002, 165(5):670–676.PubMedGoogle Scholar
  48. 48.
    Olson LJ, Somers VK: Sleep apnea: implications for heart failure. Curr Heart Fail Rep 2007, 4(2):63–69.CrossRefPubMedGoogle Scholar
  49. 49.
    Hanly P, Zuberi-Khokhar N: Daytime sleepiness in patients with congestive heart failure and Cheyne-Stokes respiration. Chest 1995, 107(4):952–958.CrossRefPubMedGoogle Scholar
  50. 50.
    Wang H, Parker JD, Newton GE, et al.: Influence of obstructive sleep apnea on mortality in patients with heart failure. J Am Coll Cardiol 2007, 49(15):1625–1631.CrossRefPubMedGoogle Scholar
  51. 51.
    Javaheri S, Shukla R, Zeigler H, Wexler L: Central sleep apnea, right ventricular dysfunction, and low diastolic blood pressure are predictors of mortality in systolic heart failure. J Am Coll Cardiol 2007, 49(20):2028–2034.CrossRefPubMedGoogle Scholar
  52. 52.
    Gami AS, Pressman G, Caples SM, et al.: Association of atrial fibrillation and obstructive sleep apnea. Circulation 2004, 110(4):364–367.CrossRefPubMedGoogle Scholar
  53. 53.
    Kanagala R, Murali NS, Friedman PA, et al.: Obstructive sleep apnea and the recurrence of atrial fibrillation. Circulation 2003, 107(20):2589–2594.PubMedGoogle Scholar
  54. 54.
    Somers VK, Dyken ME, Mark AL, Abboud FM: Parasympathetic hyperresponsiveness and bradyarrhythmias during apnoea in hypertension. Clin Auton Res 1992, 2(3):171–176.CrossRefPubMedGoogle Scholar
  55. 55.
    Otto ME, Belohlavek M, Romero-Corral A, et al.: Comparison of cardiac structural and functional changes in obese otherwise healthy adults with versus without obstructive sleep apnea. Am J Cardiol 2007, 99(9):1298–1302.CrossRefPubMedGoogle Scholar
  56. 56.
    Sauer WH, McKernan ML, Lin D, et al.: Clinical predictors and outcomes associated with acute return of pulmonary vein conduction during pulmonary vein isolation for treatment of atrial fibrillation. Heart Rhythm 2006, 3(9):1024–1028.CrossRefPubMedGoogle Scholar
  57. 57.
    Campos-Rodriguez F, Pena-Grinan N, Reyes-Nunez N, et al.: Mortality in obstructive sleep apnea-hypopnea patients treated with positive airway pressure. Chest 2005, 128(2):624–633.CrossRefPubMedGoogle Scholar
  58. 58.
    Milleron O, Pilliere R, Foucher A, et al.: Benefits of obstructive sleep apnoea treatment in coronary artery disease: a long-term follow-up study. Eur Heart J 2004, 25(9):728–734.CrossRefPubMedGoogle Scholar
  59. 59.
    Drager LF, Bortolotto LA, Figueiredo AC, et al.: Effects of continuous positive airway pressure on early signs of atherosclerosis in obstructive sleep apnea. Am J Respir Crit Care Med 2007, 176(7):706–712.CrossRefPubMedGoogle Scholar
  60. 60.
    Hanly P, Sasson Z, Zuberi N, Lunn K: ST-segment depression during sleep in obstructive sleep apnea. Am J Cardiol 1993, 71(15):1341–1345.CrossRefPubMedGoogle Scholar
  61. 61.
    Franklin KA, Nilsson JB, Sahlin C, Naslund U: Sleep apnoea and nocturnal angina. Lancet 1995, 345(8957):1085–1087.CrossRefPubMedGoogle Scholar
  62. 62.
    Kaneko Y, Floras JS, Usui K, et al.: Cardiovascular effects of continuous positive airway pressure in patients with heart failure and obstructive sleep apnea. N Engl J Med 2003, 348(13):1233–1241.PubMedGoogle Scholar
  63. 63.
    Ryan CM, Usui K, Floras JS, Bradley TD: Effect of continuous positive airway pressure on ventricular ectopy in heart failure patients with obstructive sleep apnoea. Thorax 2005, 60(9):781–785.CrossRefPubMedGoogle Scholar
  64. 64.
    Usui K, Bradley TD, Spaak J, et al.: Inhibition of awake sympathetic nerve activity of heart failure patients with obstructive sleep apnea by nocturnal continuous positive airway pressure. J Am Coll Cardiol 2005, 45(12):2008–2011.CrossRefPubMedGoogle Scholar
  65. 65.
    Javaheri S: Effects of continuous positive airway pressure on sleep apnea and ventricular irritability in patients with heart failure. Circulation 2000, 101(4):392–397.PubMedGoogle Scholar
  66. 66.•
    Khayat RN, Abraham WT, Patt B, et al.: In-hospital treatment of obstructive sleep apnea during decompensation of heart failure. Chest 2009, 136(4):991–997.CrossRefPubMedGoogle Scholar
  67. 67.
    Pepperell JC, Maskell NA, Jones DR, et al.: A randomized controlled trial of adaptive ventilation for Cheyne-Stokes breathing in heart failure. Am J Respir Crit Care Med 2003, 168(9):1109–1114.CrossRefPubMedGoogle Scholar
  68. 68.
    Teschler H, Dohring J, Wang YM, Berthon-Jones M: Adaptive pressure support servo-ventilation: a novel treatment for Cheyne-Stokes respiration in heart failure. Am J Respir Crit Care Med 2001, 164(4):614–619.PubMedGoogle Scholar
  69. 69.
    Becker HF, Jerrentrup A, Ploch T, et al.: Effect of nasal continuous positive airway pressure treatment on blood pressure in patients with obstructive sleep apnea. Circulation 2003, 107(1):68–73.CrossRefPubMedGoogle Scholar
  70. 70.
    Norman D, Loredo JS, Nelesen RA, et al.: Effects of continuous positive airway pressure versus supplemental oxygen on 24-hour ambulatory blood pressure. Hypertension 2006, 47(5):840–845.CrossRefPubMedGoogle Scholar
  71. 71.
    Guilleminault C, Connolly SJ, Winkle RA: Cardiac arrhythmia and conduction disturbances during sleep in 400 patients with sleep apnea syndrome. Am J Cardiol 1983, 52(5):490–494.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Division of Pulmonary, Allergy and Critical Care MedicineEmory University School of MedicineAtlantaUSA

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