Skip to main content

Risk assessment for obstructive sleep apnea and anxiety in a Pakistani population with coronary artery disease

Sleep and Breathing volume 19, pages 291–296 (2015)Cite this article

Abstract

Purpose

Previous studies in the western world have reported the possible association of obstructive sleep apnea (OSA) with anxiety and cardiovascular diseases. However, the data from developing countries such as Pakistan remains scarce in this regard. The main aim of this study was to investigate the prevalence of coronary artery disease (CAD) patients who are at high risk of OSA and to determine the association between the risk of OSA and levels of anxiety.

Methods

The sample population consisted of 400 participants including 200 patients, who had been previously diagnosed with CAD, and 200 healthy controls. The 200 CAD patients were approached for inclusion in the study on their follow-ups after their acute symptoms had subsided. The patients were interviewed after a mean time period of 13 weeks post event. All patients with lung disease or respiratory infection were excluded from the study. The risk of OSA was determined using Berlin questionnaire, while the levels of anxiety were measured by Beck anxiety inventory scale (BAI).

Results

More than half (n = 104) of the CAD patients were at high risk of OSA while majority (n = 168) of the healthy controls were at low risk. The high risk of OSA was significantly (P < 0.0001) more prevalent in CAD patients compared with controls. It was also observed that the patients who were at high risk of OSA, among both cases and controls, had significantly (P values <0.001) higher levels of anxiety.

Conclusion

A significant proportion of CAD patients are at high risk of OSA in our region. Moreover, OSA is also associated with greater levels of anxiety in both healthy people and CAD patients.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2
Fig. 3

References

  1. Marshall NS, Won KKH, Liu PY, Cullen SRJ, Knuiman MW et al (2008) Sleep apnea as an independent risk factor for all-cause mortality: the Busselton Health Study. Sleep 31:1079–1085

    PubMed Central  PubMed  Google Scholar 

  2. Akintunde AA, Okunola OO, Oluyombo R, Oladosu YO, Opadijo OG (2012) Snoring and obstructive sleep apnoea syndrome among hypertensive Nigerians: prevalence and clinical correlates. Pan Afr Med J11:75

    Google Scholar 

  3. Lui MMS, Man MS (2012) OSA and atherosclerosis. J Thorac Dis 4:164–172

    PubMed Central  PubMed  Google Scholar 

  4. Bokinsky G, Miller M, Ault K, Husband P, Mitchell J (1995) Spontaneous platelet activation and aggregation during obstructive sleep apnea and its response to therapy with nasal continuous positive airway pressure: a preliminary investigation. Chest 108:625–630

    Article  CAS  PubMed  Google Scholar 

  5. Vgontzas AN, Papanicolaou DA, Bixler EO, Kales A, Tyson K, Chrousos GP (1997) Elevation of plasma cytokines in disorders of excessive daytime sleepiness: role of sleep disturbance and obesity. J Clin Endocrinol Metab 82:1313–1316

    Article  CAS  PubMed  Google Scholar 

  6. Baldwin CM, Griffith KA, Nieto FJ, O’Connor GT, Walsleben JA (2001) The association of sleep-disordered breathing and sleep symptoms with quality of life in the Sleep Heart Health Study. Sleep 24:96–105

    CAS  PubMed  Google Scholar 

  7. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S (1993) The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 328:1230–1235

    Article  CAS  PubMed  Google Scholar 

  8. Mirrakhimov AE, Sooronbaev T, Mirrakhimov EM (2013) Prevalence of obstructive sleep apnea in Asian adults: a systematic review of the literature. BMC Pulm Med 13:10

    Article  PubMed Central  PubMed  Google Scholar 

  9. He QY, Feng J, Zhang XL, Liang ZA, Huang SG, Kang J et al (2010) Relationship of daytime blood pressure and severity of obstructive sleep apnea among Chinese: a multi-center investigation in China. Chin Med J (Engl) 123:18–22

    Google Scholar 

  10. Kim J, In K, Kim J, You S, Kang K, Shim J et al (2004) Prevalence of sleep-disordered breathing in middle-aged Korean men and women. Am J Respir Crit Care Med 170:1108–1113

    Article  PubMed  Google Scholar 

  11. Khazaie H, Najafi F, Rezaie L, Tahmasian M, Sepehry AA, Herth FJ (2011) Prevalence of symptoms and risk of obstructive sleep apnea syndrome in the general population. Arch Iran Med 14:335–338

    PubMed  Google Scholar 

  12. Puvanendran K, Goh KL (1999) From snoring to sleep apnea in a Singapore population. Sleep Res Online 2:11–14

    CAS  PubMed  Google Scholar 

  13. Young T, Evans L, Finn L, Palta M (1997) Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women. Sleep 20:705–706

    CAS  PubMed  Google Scholar 

  14. Taj F, Aly Z, Arif O, Khealani B, Ahmed M (2009) Risk for sleep apnea syndrome in Pakistan: a cross-sectional survey utilizing the Berlin questionnaire. Sleep Breath 13:103–106

    Article  PubMed  Google Scholar 

  15. Haqqee R, Hussain SF, Mujib M, Ahmad HR (2002) A hospital based preliminary report on sleep disordered breathing in Pakistani population. J Ayub Med Coll Abbottabad 14:2–4

    CAS  PubMed  Google Scholar 

  16. Hussain SF, Zahid S, Haqqee R, Khan JA (2003) General physicians’ perspective of sleep apnea from a developing country. Southeast Asian J Trop Med Public Health 34:420–423

    PubMed  Google Scholar 

  17. Ekici M, Ekici A, Keles H, Akin A, Karlidag A, Tunckol M et al (2008) Risk factors and correlates of snoring and observed apnea. Sleep Med 9:290–296

    Article  PubMed  Google Scholar 

  18. Li KK, Kushida C, Powell NB, Riley RW, Guilleminault C (2000) Obstructive sleep apnea syndrome: a comparison between Far-East Asian and white men. Laryngoscope 110:1689–1693

    Article  CAS  PubMed  Google Scholar 

  19. 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 131:485–489

    Article  CAS  PubMed  Google Scholar 

  20. Netzer NC, Hoegel JJ, Loube D, Netzer CM, Hay B, Alvarez-Sala R et al (2003) Prevalence of symptoms and risk of sleep apnea in primary care. Chest 124:1406–1414

    Article  PubMed  Google Scholar 

  21. Sharma SK, Vasudev C, Sinha S, Banga A, Pandey RM, Handa KK (2006) Validation of the modified Berlin questionnaire to identify patients at risk for the obstructive sleep apnoea syndrome. Indian J Med Res 124:281–290

    CAS  PubMed  Google Scholar 

  22. Beck AT, Epstein N, Brown G, Steer RA (1988) An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol 56:893–897

    Article  CAS  PubMed  Google Scholar 

  23. Beck Anxiety Inventory Scoring. Mental Health Research Centre, Tehran Psychiatric Institute (Iran). http://mhrn.net/template/farsi/index.aspx. Accessed 15 December 2010

  24. Konecny T, Kuniyoshi FH, Orban M, Pressman GS, Kara T, Gami A et al (2010) Under-diagnosis of sleep apnea in patients after acute myocardial infarction. J Am Coll Cardiol 56:742–743

    Article  PubMed Central  PubMed  Google Scholar 

  25. Lee CH, Khoo SM, Tai BC, Chong EY, Lau C, Than Y et al (2009) Obstructive sleep apnea in patients admitted for acute myocardial infarction. Prevalence, predictors, and effect on microvascular perfusion. Chest 135:1488–1495

    Article  PubMed  Google Scholar 

  26. Lee CH, Khoo SM, Chan MY, Wong HB, Low AF, Phua QH et al (2011) Severe obstructive sleep apnea and outcomes following myocardial infarction. J Clin Sleep Med 7:616–621

    PubMed Central  PubMed  Google Scholar 

  27. Yumino D, Wang H, Floras JS, Newton GE, Mak S, Ruttanaumpawan P et al (2009) Prevalence and physiological predictors of sleep apnea in patients with heart failure and systolic dysfunction. J Card Fail 15:279–285

    Article  PubMed  Google Scholar 

  28. Logan AG, Perlikowski SM, Mente A, Tisler A, Tkacova R, Niroumand M et al (2001) High prevalence of unrecognized sleep apnoea in drug-resistant hypertension. J Hypertens 19:2271–2277

    Article  CAS  PubMed  Google Scholar 

  29. Kasai T, Floras JS, Bradley TD (2012) Sleep apnea and cardiovascular disease: a bidirectional relationship. Circulation 126:1495–1510

    Article  PubMed  Google Scholar 

  30. Hamm CW, Bassand JP, Agewall S, Bax J, Boersma E, Bueno H et al (2011) ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: the task force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J32:2999–3054

    Google Scholar 

  31. Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology (ESC), Steg PG, James SK, Atar D, Badano LP, Blömstrom-Lundqvist C et al (2012) ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 33:2569–2619

    Article  Google Scholar 

  32. Mooe T, Franklin KA, Holmström K, Rabben T, Wiklund U (2001) Sleep-disordered breathing and coronary artery disease: long-term prognosis. Am J Respir Crit Care Med 164:1910–1913

    Article  CAS  PubMed  Google Scholar 

  33. Valham F, Mooe T, Rabben T, Stenlund H, Wiklund U, Franklin KA (2008) Increased risk of stroke in patients with coronary artery disease and sleep apnea: a 10-year follow-up. Circulation 118:955–960

    Article  PubMed  Google Scholar 

  34. 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

    Article  PubMed  Google Scholar 

  35. Sharafkhaneh A, Giray N, Richardson P, Young T, Hirshkowitz M (2005) Association of psychiatric disorders and sleep apnea in a large cohort. Sleep 28:1405–1411

    PubMed  Google Scholar 

  36. Guglielmi O, Sánchez AI, Jurado-Gámez B, Buela-Casal G, Bardwell WA (2011) Obesity and sleep quality: the predictors of depression and anxiety in obstructive sleep apnea syndrome patients. Rev Neurol 52:515–521

    PubMed  Google Scholar 

  37. Kumar R, Macey PM, Cross RL, Woo MA, Yan-Go FL, Harper RM (2009) Neural alterations associated with anxiety symptoms in obstructive sleep apnea syndrome. Depress Anxiety 26:480–491

    Article  PubMed Central  PubMed  Google Scholar 

  38. Aurora RN, Punjabi NM (2013) Obstructive sleep apnoea and type 2 diabetes mellitus: a bidirectional association. Lancet Respir Med 1:329–338

    Article  PubMed  Google Scholar 

Download references

Conflict of interest

The authors declare no conflicts of interest.

Author information

Affiliations

  1. Dow University of Health Sciences, 109/2 Khayabane Amir Khusro Phase 6 DHA, Karachi, Pakistan

    Muhammad Shahzeb Khan, Faizan Imran Bawany, Mehwish Hussain & Syed Raza Shah

  2. Cardiac Surgery Department, Civil Hospital, DUHS, Karachi, Pakistan

    Asadullah Khan

  3. Aga Khan University Hospital, Karachi, Pakistan

    Syed Shayan Ali

  4. Cardiology Department, Civil Hospital, DUHS, Karachi, Pakistan

    Muhammad Nawaz Lashari

Authors
  1. Muhammad Shahzeb Khan
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Faizan Imran Bawany
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Asadullah Khan
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Mehwish Hussain
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Syed Shayan Ali
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Syed Raza Shah
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Muhammad Nawaz Lashari
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Muhammad Shahzeb Khan.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Khan, M.S., Bawany, F.I., Khan, A. et al. Risk assessment for obstructive sleep apnea and anxiety in a Pakistani population with coronary artery disease. Sleep Breath 19, 291–296 (2015). https://doi.org/10.1007/s11325-014-1018-5

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11325-014-1018-5

Keywords

  • Obstructive sleep apnea
  • Coronary artery disease
  • Anxiety
  • Pakistan