Abstract
Obstructive sleep apnea (OSA) is a newly recognized risk factor for the development of systemic hypertension, ischemic heart disease, and congestive heart failure. Mechanisms responsible for these links include OSA-related hypoxemia and arousal from sleepinduced increased sympathetic activity, large negative intrathoracic pressure-induced increased left ventricular transmural pressure gradient and impaired vagal activity, plus formation of oxygen radicals. Secondary phenomena include increased platelet aggregability, insulin resistance, and endothelial dysfunction with reduced endogenous nitric oxide production. Safe, nonpharmacologic, nonsurgical therapy, namely continuous positive airway pressure, can attenuate OSA and improve cardiac function and quality of life. Searching for signs or symptoms of OSA from the patient (or bed partner), namely loud habitual snoring, apneas, nocturnal choking, orthopnea, paroxysmal nocturnal dyspnea, excessive daytime sleepiness, or cardiovascular disease which is difficult to control, may reward the curious physician with another treatment avenue.
Similar content being viewed by others
References and Recommended Reading
Shanoudy H, Soliman A, Raggi P, et al.: Prevalence of patent ovale foramen and its contribution to hypoxemia in patients with obstructive sleep apnea. Chest 1998, 113:91–96.
Young T, Palta M, Dempsey J, et al.: The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993, 328:1230–1235.
Kenchaiah S, Evans JC, Levy D, et al.: Obesity and the risk of heart failure. N Engl J Med 2002, 347:305–313.
Solin P, Roebuck T, Johns DP, et al.: Peripheral and central ventilatory responses in central sleep apnea with and without heart failure. Am J Respir Crit Care Med 2000, 162:2194–2200.
Solin P, Bergin P, Richardson M, et al.: Influence of pulmonary capillary wedge pressure on CSA in heart failure. Circulation 1999, 99:1574–1579.
Brooks D, Horner RL, Kozar LF, et al.: Obstructive sleep apnea as a cause of systemic hypertension. Evidence from a canine model. J Clin Invest 1997, 99:106–109.
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, 163:19–25.
Worsnop CJ, Naughton MT, Barter CE, et al.: The prevalence of obstructive sleep apnea in hypertensives. Am J Respir Crit Care Med 1998, 157:111–115.
Nieto FJ, Young TB, Lind BK, et al.: Association of sleepdisordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study. JAMA 2000, 283:1829–1836.
Peppard PE, Young T, Palta M, Skatrud J: Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med 2000, 342:1378–1384.
Logan AG, Perlikowski SM, Mente A, et al.: High prevalence of unrecognized sleep apnea in drug-resistant hypertension. J Hypertens 2001, 19:2271–2277.
Pepperell JC, Ramdassingh-Dow S, Crosthwaite N, et al.: Ambulatory blood pressure following therapeutic and subtherapeutic nasal CPAP for OSA: a randomised controlled parallel trial. Lancet 2002, 359:204–210.
Becker HF, Jerrentrup A, Ploch T, et al.: Effect of nasal CPAP treatment on blood pressure in patients with OSA. Circulation 2003, 107:68–73.
Chobanian AV, Bakris GL, Black HR, et al.: Joint national committee on prevention, detection, evaluation and treatment of high blood pressure. Hypertension 2003, 42:1206–1252. This paper accepts OSA as an important reversible cause of hypertension.
Mooe T, Franklin KA, Wiklund U, et al.: Sleep-disordered breathing and myocardial ischemia in patients with coronary artery disease. Chest 2000, 117:1597–1602.
Koehler U, Trautmann M, Trautmann R, et al.: Does sleep apnea increase the risk of myocardial infarct during sleep? Z Kardiol 1999, 88:410–417.
Aboyans V, Cassat C, Lacroix P, et al.: Is the morning peak of acute myocardial infarction’s onset due to sleep-related breathing disorders? A prospective study. Cardiology 2000, 94:188–192.
Hung J, Whitford EG, Parsons RW, Hillman DR: Association of sleep apnea with myocardial infarction in men. Lancet 1990, 336:261–264.
Peker Y, Hedner J, Norum J, et al.: Increased incidence of cardiovascular disease in middle-aged men with OSA: a 7-year follow-up. Am J Respir Crit Care Med 2002, 166:159–165.
Peled N, Abinader EG, Pillar G, et al.: Nocturnal ischemic events in patients with OSA syndrome and ischemic heart disease: effects of continuous positive air pressure. J Am Coll Cardiol 1999, 34:1744–1749.
Franklin KA, Nilsson JB, Sahlin C, Naslund U: Sleep apnea in nocturnal angina. Lancet 1995, 345:1085–1087.
Lavie L, Vishnevsky A, Lavie P: Evidence for lipid peroxidation in obstructive sleep apnea. Sleep 2004, 27:123–128.
Ip MS, Tse HF, Lam B, et al.: Endothelial function in obstructive sleep apnea and response to treatment. Am J Respir Crit Care Med 2004, 169:348–353.
Tazaki T, Minoguchi K, Yokoe T, et al.: Increased levels of and activity of metalloproteinase-9 in obstructive sleep apnea syndrome. Am J Respir Crit Care Med 2004, 170:1354–1359.
Kato M, Roberts-Thompson P, Phillips BG, et al.: Impairment of endothelium-dependent vasodilation of resistance vessels in patients with obstructive sleep apnea. Circulation 2000, 102:2607–2610.
Curry BD, Bain JL, Yan JG, et al.: Vibration injury damages arterial endothelial cells. Muscle Nerve 2002, 25:527–534.
Drage LF, Bortolotto LA, Lorenzi MC, et al.: Early signs of atherosclerosis in obstructive sleep apnea. Am J Respir Crit Care Med 2005, 172:613–618.
Chan J, Sanderson J, Chan W, et al.: Prevalence of sleepdisordered breathing in diastolic heart failure. Chest 1997, 111:1488–1493.
Sin DD, Fitzgerald F, Parker JD, et al.: Risk factors for central and obstructive sleep apnea in 450 men and women with congestive heart failure. Am J Respir Crit Care Med 1999, 160:1101–1106.
Laaban JP, Pascal-Sebaoun S, Bloch E, et al.: Left ventricular systolic dysfunction in patients with obstructive sleep apnea syndrome. Chest 2002, 122:1133–1238.
Alchanatasis M, Tourkohoriti G, Kosmas EN, et al.: Evidence for left ventricular dysfunction in patients with obstructive sleep apnea syndrome. Eur Respir J 2002, 20:1239–1245.
Fung JW, Li TS, Choy DK, et al.: Severe obstructive sleep apnea is associated with left ventricular diastolic dysfunction. Chest 2002, 121:422–429.
Amin RS, Kimball TR, Bean JA, et al.: Left ventricular hypertrophy and abnormal ventricular geometry in children and adolescents with obstructive sleep apnea. Am J Respir Crit Care Med 2002, 165:1395–1399.
Fletcher EC, Proctor M, Yu J, et al.: Pulmonary edema develops after recurrent obstructive apneas. Am J Respir Crit Care Med 1999, 160:1688–1696.
Parker JD, Brooks D, Kozar LF, et al.: Acute and chronic effects of airway obstruction on canine left ventricular performance. Am J Respir Crit Care Med 1999, 160:1888–1896.
Scharf SM, Bianco JA, Tow DE, et al.: The effects of large negative intrathoracic pressure on left ventricular function in patients with coronary artery disease. Circulation 1981, 63:871–875.
Serizawa T, Vogel M, Apstein CS, Grossman W: Comparison of acute alterations in left ventricular relaxation in left ventricular relaxation and diastolic chamber stiffness induced by hypoxia and ischemia. J Clin Invest 1981, 68:91–102.
Guardiola J, Yu J, Hasan N, Fletcher EC: Evening and morning blood gases in patients with OSA. Sleep Med 2004, 5:489–493.
Buda AJ, Schroeder JS, Guilleminault C: Abnormalities of pulmonary artery wedge pressures in sleep-induced apnea. Int J Cardiol 1981, 1:67–74.
Cloward TV, Walker JM, Farney RJ, Anderson JL: Left ventricular hypertrophy is a common echocardiographic abnormality in severe OSA and reverses with CPAP. Chest 2003, 124:594–601.
Malone S, Liu PP, Holloway R, et al.: OSA in patients with idiopathic dilated cardiomyopathy: effects of CPAP. Lancet 1991, 38:1480–1484.
Krieger J, Grucker D, Sforza E, et al.: LVEF in OSA. Effect of long term treatment with nasal continuous positive airway pressure. Chest 1991, 100:917–921.
Kaneko Y, Floras JS, Usui K, et al.: Cardiovascular effects of CPAP in patients with CHF and OSA. N Engl J Med 2003, 348:1233–1241. This study confirmed prior before and after studies with a randomized, controlled trial that CPAP augments cardiac function and reduces blood pressure and LV chamber size in patients with CHF and OSA over 1 month.
Mansfield D, Gollogly NC, Bergin P, et al.: Controlled trial of CPAP in OSA and heart failure. Am J Respir Crit Care Med 2004, 169:361–366. This study published also confirmed CPAP augmented cardiac function, reduced sympathetic activity and improved quality of life in CHF patients with OSA over 3 months.
Artz M, Harth M, Blumberg F, Pfeifer M: Nocturnal continuous positive airway pressure improves ventilatory efficiency during exercise in congestive heart failure. Am J Respir Crit Care Med 2004, 169:A747.
Robinson GV, Stradling JR, Davies RJ, Roberts IS: Post mortem diagnosis of fatal obstructive sleep apnea. Histopathology 2004, 45:542.
Lindberg E, Janson C, Svardsudd K, et al.: Increased mortality among sleepy snorers: a prospective population study. Thorax 1998, 53:631–637.
Veale D, Chailleux E, Hoorelbeke-Ramon A, et al.: Mortality of sleep apnea patients treated by CPAP registered with ANTIADIR. Eur Resp J 2000, 15:326–331.
Marti G, Sampol G, Munoz X, et al.: Mortality in severe sleep apnea/hypopnoea syndrome patients: impact of treatment. Eur Resp J 2002, 20:1511–1518.
Roebuck T, Solin P, Kaye DM, et al.: Increased long term mortality due to sleep apnea in heart failure is yet to be proven. Eur Respir J 2004, 23:735–740.
Gami AS, Howard DE, Olson EJ, Somers VK: Day-night pattern of sudden death in obstructive sleep apnea. N Engl J Med 2005, 352:1206–1214.
Bersten AD, Holt AW, Vedig A, et al.: Treatment of severe cardiogenic pulmonary edema with CPAP. N Engl J Med 1991, 325:1825–1830.
Kaye DM, Mansfield D, Aggarwal A, et al.: Acute effects of CPAP on cardiac sympathetic tone in CHF. Circulation 2001, 103:2336–2338.
Naughton MT: Effect of CPAP on intrathoracic and left ventricular transmural pressure in CHF. Circulation 1995, 91:1725–1731.
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Naughton, M.T. The link between obstructive sleep apnea and heart failure: Underappreciated opportunity for treatment. Curr Heart Fail Rep 3, 183–188 (2006). https://doi.org/10.1007/s11897-006-0020-z
Issue Date:
DOI: https://doi.org/10.1007/s11897-006-0020-z