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Sleep apnea and Stroke Olukayode Ogunrinde, MD Sleep Fellow Stanford Hospital and Clinic Overview • Sleep apnea (OSA) • Stroke • How OSA/Stroke are connected • Supporting Evidence • Prevention/therapy • Summary Sleep Apnea • > 18 million affect (1 in 15 Americans) • Prevalence (Men 24%, Women 9%) • 10 - 20% are children • Untreated or undiagnosed >80% • Health cost for individual with untreated sleep apnea is about $1,336/yr National Sleep Foundation Types of Sleep Apnea • Obstructive (Apnea and Hypopnea) • Central Sleep Apnea • Mixed Sleep Apnea What is Obstructive sleep apnea • Recurrent episode of airway obstruction during sleep • lasting at least 10 seconds • can be associated with arousal or decrease in oxygen level OSA Somers et al, JACC How is OSA measured AHI (Apnea/hypopnea index) or RDI (Respiratory Disturbance Index) • AHI < 5 (normal) • AHI 5 -15 (mild) • AHI >15 - 30 (moderate) • AHI > 30 (severe) Symptoms/signs of OSA • Snoring • Gasping or choking from sleep • Excessive daytime sleepiness • Daytime fatigue • Cognitive dysfunction (memory, concentration) • Change in mood (irritable) • Unrefreshed sleep Cause of symptoms • Hypoxemia (low oxygenation at night) • Frequent arousal during the night Untreated OSA increases your Risk • High blood pressure • Heart disease (abnormal heart rhythm, heart failure) • Stroke • Depression • Diabetes • Accidents • Death Stroke (cerebrovascular disease) • 2nd - cause of death (worldwide) • 3rd - cause of death (USA, #1 heart & #2 cancer) • #1 leading cause of disability in US • Affects 700,000 individual; annually • 150,000 people die per year • Stroke health care cost >$40 billion/year Stroke - Definition • Reduction or loss of blood flow to a particular region of the brain and it is associated with a neurological deficit (transient or permanent). Types of Stroke • Ischemic stroke (clogged pipe) – TIA (transient ischemic attack)- AKA (Mini-stroke) – Mostly seen in OSA patients • Cerebral Hemorrhage - bleeding into brain and surrounding tissue (Busted pipe) Ischemic Stroke Hemorrhagic stroke Symptoms of stroke • Weakness • Numbness • Language disturbance • Visual changes • Dizziness • Headache • Unsteadiness Risk factors for stroke • High blood pressure • Heart disease (abnormal heart rhythm) • Diabetes • High cholesterol • Smoking • Age • Sleep apnea (OSA) • Obesity Stroke • OSA is common in Stroke patients (70%) • Stroke occurs in early morning (4am and 12 pm) • Increase risk with higher AHI/RDI • Increase risk with age • Increase risk in people who have sleep apnea and heart disease • OSA worsens after stroke ( esp acute phase) What connects OSA to stroke • Sleep apnea • Stroke risk factors increase your risk are High blood pressure High blood pressure Heart disease Heart disease Abnormal heart rhythm Atrial fibrillation Diabetes Diabetes How does sleep apnea lead to stroke • Decrease cerebral blood flow during apnea • Hypoxemia (low oxygenation) • Sympathetic activation (increase BP/HR) • Abnormal heart rhythm and rate How does sleep apnea lead to stroke • Coagulation (increase blood clot formation) • Disruption of lining of blood vessels • Inflammatory markers (CRP, IL6) • Metabolic deregulation ( Insulin, leptin) Portela et al, cerebrovascular diseases Study • Conducted at Yale Medical Center • 1022 participants enrolled but only 842 completed – 573 with OSA (AHI- 35), 325 w/o OSA ( AHI<2) • Mean age - 60yrs old • Follow up of 2-4yrs • Adjusted for age/sex/race, smoking, alcohol intake, BMI, DM, HTN, AF, high cholesterol. Results • OSA group - 22 stroke, 50 death • Control group - 2 stroke, 16 death Hazard ratio 1.97; (95% CI 1.12-3.48), P=0.01 Yaggi et al, NEJM, 2005 More evidence • Another study of 1189 subjects from the general population • Individuals (#99) with Sleep apnea (AHI>20) was associated with increased risk of having a stroke (OR 4.31; 95% CI 1.31-14.15; P=0.02) Arzt et al, AM J Respir Crit care Med, 2005 Who snores more, Men or women? Snoring • Studies suggest it is a risk factor for ischemic stroke • Multiple Studies show it increases blood pressure • Vibration from snoring increase plaque formation in the carotid artery. Snoring • Study from Japan • 167 patients with OSA • mean age - 47 • After control for High BP, DM, high cholesterol • Results shows patients with – High AHI have increase carotid artery thickness (measured by ultrasound) – Decrease thickness after CPAP therapy Suzuki et al, Sleep, 2004 Brain scan in OSA patients • Brain MRI shows silent brain infarct in 25% of patient with moderate to severe OSA Minoguchi et al, AM J Respir Crit care Med, 2007 • Higher prevalence of sleep apnea in patients with vascular dementia compared with patients with Alzheimer’s disease or control of similar age Erkinjuntti et al, sleep, 1987 How does the Presence of OSA Affect Stroke Recovery? • Studies suggest that stroke patients with OSA have – Reduce motivation – decrease cognitive capacity – Prolong rehab stay – May increase the risk of recurrent stroke and death. How can you decrease your risk of stroke if you have obstructive sleep Apnea? Lifestyle changes • Weight loss • Sleep with head elevated with wedge or pillow • Avoid sleeping supine • Avoid alcohol consumption at night Positive pressure therapy CPAP or Bilevel devices Use of CPAP and stroke risk • Successful treatment of sleep apnea with CPAP lowers blood pressure. (indirectly lowers the risk of stroke) • Improves blood flow to the brain • CPAP therapy reduces mortality, especially after stroke. CPAP Study • 5yr follow study from Spain • 166 patients with stroke • CPAP treatment offered to patient with AHI > 20 • Patient followed for 1,3,6, then q6 months for 5 yrs Martinez-garcia et al, Am J respir Crit Care med, 2009 Issues of CPAP compliance • Study of 105 pts shows only about <70% of patient with OSA and stroke actually adhere to CPAP therapy • CPAP compliance is poor • Difficulty using mask • Motor deficit (facial weakness) • Difficulty understanding Wessendorf et al Other OSA treatments • But no studies to justify efficacy • Oral appliances( may decrease snoring) • Surgery ( Jaw advancement, soft tissue) Cure for OSA • Tracheotomy Summary • OSA is a risk factor for Stroke • OSA patients have an increase of stroke and death • OSA needs to be treated • Some evidence shows CPAP decreases the risk of stroke and mortality in OSA patients References: • Young T, Finn Laurel, Peppard P, Szklo-Coxe M, Austin D, Nieto F, Stubbs R, Hia K. Sleep-disordered breathing and Mortality: eighteen year follow-up of the Wisconsin sleep cohort. Sleep 2008; 31 (8):1071-1078 • Shamsuzzaman A, Gersh BJ, Somers VK. Obstructive Sleep Apnea: Implications for Cardiac and Vascular disease. JAMA 2003; 290:1906-1914 • Pack AI, Gislason T. Obstructive Sleep Apnea and cardiovascular Disease: A Perspective and Future directions. Progress in cardiovascular diseases;51:434-451. • Munoz R, Duran-Cantolla J, Martinez-Vila E et al. Severe sleep apnea and risk of Ischemic stroke in the elderly. Stroke 2006;37:2317-2321. • Yaggi HK, Concato J, Kernan W. Obstructive sleep apnea as a risk factor for stroke and death. NEJM 2005; 353: 2034- 2041. • Culebras Antonio. Sleep and Stroke. Seminars in Neurology/Volume 2009; 29: 438-445. • Somers VK, White DP, Amin R. Sleep Apnea and Cardiovascular. J AM Coll Cardiology 2008;52:686-717. • Portela PC, Fumado JC, Garcia HQ, Borrego FR. Sleep-disorder breathing and acute stroke. Cerebrovascular Disease 2009; 27: 104-110. • Martinez-Garcia MA, Soler-Cataluna JJ. 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: 36-41. • Bonnin-Vilaplana M, Arboix A, Parra et al. Journal of Neurology 2009. • Butt, M, et al, Obstructive sleep apnea and cardiovascular disease, Int J Cardiol ( 2009). • Bassetti Claudio L, Milanova M, and Gugger M. Sleep- Disordered Breathing and Acute Ischemic Stroke: Diagnosis, Risk factors, Treatment, Evolution, and Long-term Clinical Outcome. Stroke 2006; 37: 967-972. • Suzuki T, Nakano H, Maekawa J, et al. Obstructive sleep Apnea and Carotid-Artery Intima- Media Thickness. SLEEP 2004; 27: 129-133. • Tosun A, Kokturk O, Ciftci TU, Sepici V. Obstructive Sleep Apnea in Ischemic Stroke Patients. Clinics. 2008; 63; 625-630. • Arzt M, Young T, Finn L, Skatrud JB, Bradley TD. Association of sleep- disorded breathing and the occurrence of stroke. Am J Respir Crit care Med 2005; 172(11); 1447-1451. • Minoguchi K, Yokeo T, Tazaki T, et al. Silent Brain infarction and platelet activation in obstructive sleep apnea. Am j Respir Crit Care Med. 2007;175:612-617. • Netzer N, Werner P et al, Blood flow of the middle cerebral artery with sleep disorder breathing: correlation with obstructive hypopneas. Stroke 1998;29(1): 87-93.
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