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High risk for sleep apnea in the Berlin questionnaire and coronary artery disease

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Abstract

Introduction

Obstructive sleep apnea (OSA) affects up to 30% of the adult population and is a risk factor for coronary artery disease (CAD). The diagnostic process, involving polysomnography, may be complex. Berlin questionnaire (BQ) is a validated and economical screening tool.

Purpose

The aim of this study was to assess the performance of the BQ for the diagnosis of OSA in individuals with angina complaints.

Methods

Patients undergoing diagnostic cineangiography, portable type III polysomnography to determine the apnea-hypopnea index (AHI), and who answered the BQ were included. We excluded patients older than 65 years that were smokers, diabetics, and morbidly obese. High risk for OSA was based on positive responses in two of three symptom criteria of the BQ. CAD was defined by the presence of >50% lesion in coronary arteries.

Results

In 57 included cases, high risk in the BQ indicates significant odds ratio [95% confidence interval] for the presence of CAD (4.5[1.03–19.25], P = 0.045), adjusted for usual confounders: gender, age, and body mass index. The sensitivity and the specificity of BQ for CAD were 70% and 48%, respectively; the positive and negative predictive values are 56% and 64%.

Conclusions

In conclusion, simple questionnaire-based diagnostic tools can be included in the screening procedures of patients with angina to detect the need for further OSA evaluation. In conclusion, the BQ is an effective instrument for this purpose.

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References

  1. Young T, Peppard PE, Gottlieb DJ (2002) Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med 165:1217–1239. doi:10.1164/rccm.2109080

    Article  PubMed  Google Scholar 

  2. Lee W, Nagubadi S, Kryger MH, Mokhlesi B (2008) Epidemiology of obstructive sleep apnea: a population-based perspective. Expert Rev Respir Med 2:349–364

    Article  PubMed  Google Scholar 

  3. Tufik S, Santos-Silva R, Taddei JA, Bittencourt LR (2010) Obstructive sleep apnea syndrome in the Sao Paulo Epidemiologic Sleep Study. Sleep Med 11:441–446

    Article  PubMed  Google Scholar 

  4. Drager LF, Bortolotto LA, Lorenzi MC, Figueiredo AC, Krieger EM, Lorenzi-Filho G (2005) Early signs of atherosclerosis in obstructive sleep apnea. Am J Respir Crit Care Med 172:613–618. doi:10.1164/rccm.200503-340OC

    Article  PubMed  Google Scholar 

  5. Kim SH, Cho GY, Baik I, Kim J, Kim SJ, Lee JB, Lim HE, Lim SY, Park J, Shin C (2009) Association of coronary artery calcification with obstructive sleep apnea and obesity in middle-aged men. Nutr Metab Cardiovasc Dis 20:575–582. doi:10.1016/j.numecd.2009.05.011

    Article  PubMed  Google Scholar 

  6. Butt M, Dwivedi G, Khair O, Lip GY (2009) Obstructive sleep apnea and cardiovascular disease. Int J Cardiol 139:7–16. doi:10.1016/j.ijcard.2009.05.021

    Article  PubMed  Google Scholar 

  7. Bradley TD, Floras JS (2009) Obstructive sleep apnoea and its cardiovascular consequences. Lancet 373:82–93. doi:10.1016/S0140-6736(08)61622-0

    Article  PubMed  Google Scholar 

  8. Somers VK, White DP, Amin R, Abraham WT, Costa F, Culebras A, Daniels S, Floras JS, Hunt CE, Olson LJ, Pickering TG, Russell R, Woo M, Young T (2008) 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. In collaboration with the National Heart, Lung, and Blood Institute National Center on Sleep Disorders Research (National Institutes of Health). Circulation 118:1080–1111

    Article  PubMed  Google Scholar 

  9. Hayashi M, Fujimoto K, Urushibata K, Uchikawa S, Imamura H, Kubo K (2003) Nocturnal oxygen desaturation correlates with the severity of coronary atherosclerosis in coronary artery disease. Chest 124:936–941

    Article  PubMed  Google Scholar 

  10. Peker Y, Carlson J, Hedner J (2006) Increased incidence of coronary artery disease in sleep apnoea: a long-term follow-up. Eur Respir J 28:596–602. doi:10.1183/09031936.06.00107805

    Article  PubMed  CAS  Google Scholar 

  11. Tasali E, Mokhlesi B, Van Cauter E (2008) Obstructive sleep apnea and type 2 diabetes: interacting epidemics. Chest 133:496–506. doi:10.1378/chest.07-0828

    Article  PubMed  Google Scholar 

  12. Reichmuth KJ, Austin D, Skatrud JB, Young T (2005) Association of sleep apnea and type II diabetes: a population-based study. Am J Respir Crit Care Med 172:1590–1595. doi:10.1164/rccm.200504-637OC

    Article  PubMed  Google Scholar 

  13. Phillipson EA (1993) Sleep apnea-a major public health problem. N Engl J Med 328:1271–1273

    Article  PubMed  CAS  Google Scholar 

  14. Yaggi HK, Concato J, Kernan WN, Lichtman JH, Brass LM, Mohsenin V (2005) Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med 353:2034–2041

    Article  PubMed  CAS  Google Scholar 

  15. Marin JM, Carrizo SJ, Vicente E, Agusti AG (2005) Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet 365:1046–1053. doi:10.1016/S0140-6736(05)71141-7

    PubMed  Google Scholar 

  16. Shah NA, Yaggi HK, Concato J, Mohsenin V (2010) Obstructive sleep apnea as a risk factor for coronary events or cardiovascular death. Sleep Breat 14:131–136. doi:10.1007/s11325-009-0298-7

    Article  Google Scholar 

  17. Young T, Finn L, Peppard PE, Szklo-Coxe M, Austin D, Nieto FJ, Stubbs R, Hla KM (2008) Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin sleep cohort. Sleep 31:1071–1078

    PubMed  Google Scholar 

  18. Punjabi NM, Caffo BS, Goodwin JL, Gottlieb DJ, Newman AB, O’Connor GT, Rapoport DM, Redline S, Resnick HE, Robbins JA, Shahar E, Unruh ML, Samet JM (2009) Sleep-disordered breathing and mortality: a prospective cohort study. PLoS Med. doi:10.1371/journal.pmed.1000132

    PubMed  Google Scholar 

  19. Selim B, Won C, Yaggi HK (2010) Cardiovascular consequences of sleep apnea. Clin Chest Med 31:203–220. doi:10.1016/j.ccm.2010.02.010

    Article  PubMed  Google Scholar 

  20. Attal P, Chanson P (2010) Endocrine aspects of obstructive sleep apnea. J Clin Endocrinol Metab 95:483–495. doi:10.1210/jc.2009-1912

    Article  PubMed  CAS  Google Scholar 

  21. Gami AS, Hodge DO, Herges RM, Olson EJ, Nykodym J, Kara T, Somers VK (2007) Obstructive sleep apnea, obesity, and the risk of incident atrial fibrillation. J Am Coll Cardiol 49:565–571. doi:10.1016/j.jacc.2006.08.060

    Article  PubMed  Google Scholar 

  22. Eikermann M, Jordan AS, Chamberlin NL, Gautam S, Wellman A, Lo YL, White DP, Malhotra A (2007) The influence of aging on pharyngeal collapsibility during sleep. Chest 131:1702–1709. doi:10.1378/chest.06-2653

    Article  PubMed  Google Scholar 

  23. Knorst MM, Souza FJ, Martinez D (2008) Obstructive sleep apnea-hypopnea syndrome:association with gender, obesity and sleepiness-related factors. J Bras Pneumol 34:490–496. doi:10.1590/S1806-37132008000700009

    Article  PubMed  Google Scholar 

  24. Ye L, Pien GW, Weaver TE (2000) Gender differences in the clinical manifestation of obstructive sleep apnea. Sleep Med 9(10):1075–1084

    Google Scholar 

  25. Libby P, Theroux P (2005) Pathophysiology of coronary artery disease. Circulation 111:3481–3488. doi:10.1161/CIRCULATIONAHA.105.537878

    Article  PubMed  Google Scholar 

  26. Dempsey JA, Veasey SC, Morgan BJ, O’Donnell CP (2010) Pathophysiology of sleep apnea. Physiol Rev 90:47–112

    Article  PubMed  CAS  Google Scholar 

  27. Graille V, Ferrières J, Evans A, Amouyel P, Arveiler D, Luc G, Ducimetière P (2000) Associations between classical cardiovascular risk factors and coronary artery disease in two countries at contrasting risk for myocardial infarction: the PRIME study. Int J Cardiol 74:191–198. doi:10.1016/S0167-5273(00)00283-7

    Article  PubMed  CAS  Google Scholar 

  28. Yumino D, Tsurumi Y, Takagi A, Suzuki K, Kasanuki H (2007) Impact of obstructive sleep apnea on clinical and angiographic outcomes following percutaneous coronary intervention in patients with acute coronary syndrome. Am J Cardiol 99:26–30. doi:10.1016/j.amjcard.2006.07.055|

    Article  PubMed  Google Scholar 

  29. Lorenzi-Filho G, Drager LF (2007) Obstructive sleep apnea and atherosclerosis: a new paradigm. Am J Respir Crit Care Med 175:1219–1221. doi:10.1164/rccm.200703-458ED

    Article  PubMed  Google Scholar 

  30. Southwell C, Moallem M, Auckley D (2008) Cardiologist’s knowledge and attitudes about obstructive sleep apnea: a survey study. Sleep Breath 12:295–302. doi:10.1007/s11325-008-0170-1

    Article  PubMed  Google Scholar 

  31. Cassar A, Morgenthaler TI, Lennon RJ, Rihal CS, Lerman A (2007) Treatment of obstructive sleep apnea is associated with decreased cardiac death after percutaneous coronary intervention. J Am Coll Cardiol 50:1310–1314. doi:10.1016/j.jacc.2007.06.028

    Article  PubMed  Google Scholar 

  32. Buchner NJ, Sanner BM, Borgel J, Rump LC (2007) Continuous positive airway pressure treatment of mild to moderate obstructive sleep apnea reduces cardiovascular risk. Am J Respir Crit Care Med 176:1274–1280. doi:10.1164/rccm.200611-1588OC

    Article  PubMed  Google Scholar 

  33. Martínez-García MA, Soler-Cataluña JJ, Ejarque-Martínez L, Soriano Y, Román-Sánchez P, Illa FB, Canal JM, Durán-Cantolla J (2009) 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 180:36–41. doi:10.1164/rccm.200611-1588OC

    Article  PubMed  Google Scholar 

  34. Chung S, Yoon IY, Lee CH, Kim JW (2010) The effects of nasal continuous positive airway pressure on vascular functions and serum cardiovascular risk factors in obstructive sleep apnea syndrome. Sleep Breath. doi:10.1007/s11325-009-0323-x

    Google Scholar 

  35. Kushida CA, Littner MR, Morgenthaler T, Alessi CA, Bailey D, Coleman J Jr, Friedman L, Hirshkowitz M, Kapen S, Kramer M, Lee-Chiong T, Loube DL, Owens J, Pancer JP, Wise M (2005) Practice parameters for the indications for polysomnography and related procedures: an update for 2005. Sleep 28:499–521

    PubMed  Google Scholar 

  36. Collop NA, Anderson WM, Boehlecke B, Claman D, Goldberg R, Gottlieb DJ, Hudgel D, Sateia M, Schwab R (2007) Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. Portable Monitoring Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med 15(3):737–747

    Google Scholar 

  37. Tonelli de Oliveira AC, Martinez D, Vasconcelos LF, Gonçalves SC, Lenz MC, Fuchs SC, Gus M, Abreu-Silva EO, Moreira LB, Fuchs FD (2009) Diagnosis of obstructive sleep apnea syndrome and its outcomes with home portable monitoring. Chest 135:330–336. doi:10.1378/chest.08-1859

    Article  PubMed  Google Scholar 

  38. Lee-Chiong L (2010) Best of sleep medicine 2010. An annual collection of scientific literature.

  39. Ayas NT, Fox J, Epstein L, Ryan CF, Fleetham JA (2010) Initial use of portable monitoring versus polysomnography to confirm obstructive sleep apnea in symptomatic patients: an economic decision model. Sleep Med 11:320–324

    Article  PubMed  CAS  Google Scholar 

  40. Netzer NC, Stoohs RA, Netzer CM, Clark K, Strohl KP (1999) Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. Ann Intern Med 131:485–491

    PubMed  CAS  Google Scholar 

  41. Ong TH, Raudha S, Fook-Chong S, Lew N, Hsu AA (2010) Simplifying STOP-BANG: use of a simple questionnaire to screen for OSA in an Asian population. Sleep Breath. doi:10.1007/s11325-010-0350-7

    PubMed  Google Scholar 

  42. Gus M, Gonçalves SC, Martinez D, de Abreu Silva EO, Moreira LB, Fuchs SC, Fuchs FD (2008) Risk for Obstructive Sleep Apnea by Berlin Questionnaire, but not daytime sleepiness, is associated with resistant hypertension: a case-control study. Am J Hypertens 21:832–835. doi:10.1038/ajh.2008.184

    Article  PubMed  Google Scholar 

  43. Chung F, Yegneswaran B, Liao P, Chung SA, Vairavanathan S, Islam S, Khajehdehi A, Shapiro CM (2008) Validation of the Berlin questionnaire and American Society of Anesthesiologists checklist as screening tools for obstructive sleep apnea in surgical patients. Anesthesiology 108:822–830. doi:10.1097/ALN.0b013e31816d91b5

    Article  PubMed  Google Scholar 

  44. Klein C, Martinez D, Hackenhaar FS, Medeiros TM, Marcolin ML, Silveira FS, Wainstein MV, Gonçalvez SC, Benfato MS (2010) Carbonyl groups: bridging the gap between sleep disordered breathing and coronary artery disease. Free Radic Res 44:907–912

    Article  PubMed  CAS  Google Scholar 

  45. American Academy of Sleep Medicine Task Force (1999) Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. Sleep 22:667–689

    Google Scholar 

  46. The International Classification of Sleep Disorders, 2nd edition, Diagnostic and Coding Manual. Hauri, PJ, (Ed),Westchester, American Academy of Sleep Medicine, 2005

  47. Flemons WW (2002) Clinical practice. Obstructive sleep apnea. N Engl J Med 347:498–504

    Article  PubMed  Google Scholar 

  48. Pang KP, Terris DJ (2006) Screening for obstructive sleep apnea: an evidence-based analysis. Am J Otolaryngol 27:112–118. doi:10.1016/j.amjoto.2005.09.002

    Article  PubMed  Google Scholar 

  49. Chilukuri K, Dalal D, Marine JE, Scherr D, Henrikson CA, Cheng A, Nazarian S, Spragg D, Berger R, Calkins H (2009) Predictive value of obstructive sleep apnoea assessed by the Berlin Questionnaire for outcomes after the catheter ablation of atrial fibrillation. Europace 11:896–901. doi:10.1093/europace/eup064

    Article  PubMed  Google Scholar 

  50. Hiestand DM, Britz P, Goldman M, Phillips B (2006) Prevalence of symptoms and risk of sleep apnea in the US population: results from the national sleep foundation sleep in America 2005 poll. Chest 130:780–786. doi:10.1378/chest.130.3.780

    Article  PubMed  Google Scholar 

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Acknowledgments

The authors would like to thank Drs. Marco Vugman Wainstein and Jorge Pinto Ribeiro for their valuable contribution in providing data from the cineangiocoronariography.

Conflict of interest

None.

Financial support

Financial support was granted by the Brazilian Government (CAPES e CNPq grants) through a research incentive fund (FIPE) of the Hospital de Clínicas de Porto Alegre.

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Authors and Affiliations

  1. Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil

    Denis Martinez & Miguel Gus

  2. Cardiology Unit, Hospital de Clínicas Porto Alegre (HCPA), Rua Ramiro Barcelos, 2350, Porto Alegre, Rio Grande do Sul, Brazil

    Denis Martinez, Roberto Pacheco da Silva & Miguel Gus

  3. Graduate Program in Cardiology and Cardiovascular Sciences, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil

    Denis Martinez, Roberto Pacheco da Silva, Cristini Klein, Cintia Zappe Fiori, Daniela Massierer, Cristiane Maria Cassol & Miguel Gus

  4. Cardiology Unit, Hospital de Clinicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Brazil

    Denis Martinez, Roberto Pacheco da Silva, Cristini Klein, Cintia Zappe Fiori, Daniela Massierer, Cristiane Maria Cassol & Miguel Gus

  5. Graduate Program in Medical Sciences, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil

    Denis Martinez & Miguel Gus

  6. Hospital de Clinicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Brazil

    Denis Martinez & Miguel Gus

  7. Pontifical Catholic University of Rio Grande do Sul, Institute of Geriatrics and Gerontology, Porto Alegre, Brazil

    Angelo Jose Gonçalves Bos

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  1. Denis Martinez
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Correspondence to Roberto Pacheco da Silva.

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Martinez, D., da Silva, R.P., Klein, C. et al. High risk for sleep apnea in the Berlin questionnaire and coronary artery disease. Sleep Breath 16, 89–94 (2012). https://doi.org/10.1007/s11325-010-0460-2

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