Newly Diagnosed With Heart Failure? Have a Sleep Test To Diagnose Sleep Apnea and Increase Your Survival Rate

A recent study "Sleep apnea testing and outcomes in a large cohort of Medicare beneficiaries with newly diagnosed heart failure" (see abstract below) in the American Journal of Critical Care Medicine showed better outcomes and higher survival rates when patients are tested for sleep apnea and then treated.

This study was among older patients on Medicare.

Medicare now covers oral appliances as well as CPAP.

The problem with CPAP therapy is that most patients do not tolerate it. When heart failure is a issue Dental Sleep Medicine and oral appliances can be a life saver.


Am J Respir Crit Care Med. 2011 Feb 15;183(4):539-46. Epub 2010 Jul 23.
Sleep apnea testing and outcomes in a large cohort of Medicare beneficiaries with newly diagnosed heart failure.

Javaheri S, Caref EB, Chen E, Tong KB, Abraham WT.

Sleepcare Diagnostics, Cincinnati, OH 45040, USA. javaheri@snorenomore.com
Abstract

RATIONALE: Previous studies have demonstrated a high prevalence of sleep apnea (SA) in patients with chronic heart failure (HF), which is associated with higher rates of morbidity, mortality, and health care use.

OBJECTIVES: To investigate the reported incidence, treatment, outcomes, and economic cost of SA in new-onset HF in a large U.S. database.

METHODS: This retrospective cohort study used the 2003 to 2005 Medicare Standard Analytical Files and included subjects with newly diagnosed HF from the first quarter of 2004, without prior diagnosis of SA, stratified by testing, diagnosis, and treatment status.

MEASUREMENTS AND MAIN RESULTS: Among a study population of 30,719 incident subjects with HF, only 1,263 (4%) were clinically suspected to have SA. Of these, 553 (2% of the total cohort) received SA testing, and 545 received treatment. After adjustment for age, sex, and comorbidities, subjects with HF who were tested, diagnosed, and treated for SA had a better 2-year survival rate compared with subjects with HF who were not tested (hazard ratio, 0.33 [95% confidence interval, 0.21-0.51], P < 0.0001). Similarly, among subjects who were tested and diagnosed, those who were treated had a better 2-year survival rate than those who were not treated (hazard ratio, 0.49 [95% confidence interval, 0.29-0.84], P = 0.009).

CONCLUSIONS: In Medicare beneficiaries with HF, comorbid SA is most often not tested and consequently subjects are underdiagnosed and not treated. Meanwhile, in the few subjects in whom a diagnosis of SA is established and treatment is executed, survival improves significantly. These results support the importance of SA testing and treatment for patients newly diagnosed with HF.

PMID: 20656940 [PubMed - indexed for MEDLINE]

COMMENT: Its my pleasure to tell you that your article has fascinated me. You are into a wonderful work. Keep up the work.And yes i have tweeted your site ihatecpap.blogspot.com .

Transcend: Radical CPAP improvement over industry standards?

Transcend is a new "wearable CPAP" that promises to increase comfort and convenience for CPAP users. Dr Shapira the founder of I HATE CPAP applauds the company for this advancement.

Dr Shapira and the I HATE CPAP dentists do not "HATE CPAP" but rather offer comfortable alternatives to CPAP. Oral appliances are a convenient alternative to CPAP for traveling but some patients are best served by CPAP. This product should be a godsend to patients who must carry CPAP when they travel.

The 60% of patients who do not tolerate CPAP will continue to find comfortable oral appliances to be the most effective alternative to CPAP. The following information is from their site: http://somnetics.com/pages/Home1/

"Sleep anywhere. Literally.
You can with Transcend.
Never before has sleep apnea therapy been this easy. Transcend gives you freedom you’ve only dreamed of—freedom from stress, freedom of unlimited mobility, and freedom to sleep anywhere you choose.

Unlike any conventional CPAP, Transcend is incredibly hassle-free and goes where you go: driving over the road, flying off to your next business meeting, or taking that well-deserved vacation.

Transcend is the first practical, wearable sleep apnea therapy system on the market. It is small, lightweight, quiet, and vibration-free.

It’s unique, patent-pending heat moisture exchange humidification technology is clinically proven in hospitals to give you the warm, moist air you want for comfort—without the mess of a water-filled humidifier.

Plus, Transcend works with your existing mask seal* and compliance reporting is as simple as plugging into your computer and sending an email directly to your care provider.

Once you experience Transcend, you’ll see why it surpasses any CPAP you’ve ever tried. In the evolution of sleep apnea therapy, it offers an innovative replacement to old-fashioned, cumbersome CPAPs of the past.

Transcend truly fits your lifestyle, whatever it might be. So curl up in your hotel room, nestle into your sleeping bag, or stretch out in your truck cab with confidence. Transcend gives you peace of mind whether you’re traveling or at home and just want to know you can still get a full, restful night’s sleep should the power go out.

Transcend—advancing sleep apnea therapy to the highest level of comfort and mobility"

ORAL APPLIANCES ARE A CONSERVATIVE METHOD OF TREATMENT ACCORDING TO THE NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE.

THE FOLLOWING PAGE FROM THE NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE OF THE NIH IS REPRINTED FROM http://www.ninds.nih.gov/disorders/sleep_apnea/sleep_apnea.htm

IN ADDITION TO THE WELL KNOWN SYMPTOM OF EXCESSIVE DAYTIME SLEEPINESS IT ALSO RECOGNIZES "morning headaches, trouble concentrating, irritability, forgetfulness, mood or behavior changes, anxiety, and depression AS ASSOCIATED DISORDER.

WHILE MANY IN THE MEDICAL SLEEP COMMUNITY ALWAYS LOOK AT CPAP AS THE FIRST LINE TREATMENT THE NINDS RECOGNIZES ORAL APPLIANCES AS A CONSERVATIVE TREATMENT OF SLEEP APNEA. THE FIRST LINE THERAPY FOR SLEEP APNEA ARE CONSERVATIVE METHODS "Most treatment regimens begin with lifestyle changes, such as avoiding alcohol and medications that relax the central nervous system (for example, sedatives and muscle relaxants), losing weight, and quitting smoking. Some people are helped by special pillows or devices that keep them from sleeping on their backs, or oral appliances to keep the airway open during sleep." AND CPAP IS COSIDERED A LESS CONSERVATIVE APPROACH ALONG WITH SURGERY. THE ARTICLE STATES "If these conservative methods are inadequate, doctors often recommend continuous positive airway pressure (CPAP), in which a face mask is attached to a tube and a machine that blows pressurized air into the mask and through the airway to keep it open. There are also surgical procedures that can be used to remove tissue and widen the airway.

THE SLEEP COMMUNTIY OFTEN MAKES CPAP THE FIRST AND SOMETIMES ONLY TREATMENT OF CHOICE. THE MORE RATIONAL APPROACH OF THE THE NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE OF THE NIH IS A FRESH APPROACH.

WHY CONSIDR CPAP A FIRST LINE TREATMENT WHEN MOST PATIENTS DO NOT TOLERATE CPAP.

CONSIDERING SLEEP POSITION, WEIGHT LOSS AND ORAL APPLIANCES AS CONSEVATIVE APPROACHES RECOGNIZE NOT JUST THE EFFECTIVENESS OF THESE TREATMENTS BUT ALSO THE CONSERVATIVE NATURE OF THESE TREATMENTS.

THE FOLLOWING IS INFORMATION FROM THE NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SITE.

What is Sleep Apnea?
Sleep apnea is a common sleep disorder characterized by brief interruptions of breathing during sleep. These episodes usually last 10 seconds or more and occur repeatedly throughout the night. People with sleep apnea will partially awaken as they struggle to breathe, but in the morning they will not be aware of the disturbances in their sleep. The most common type of sleep apnea is obstructive sleep apnea (OSA), caused by relaxation of soft tissue in the back of the throat that blocks the passage of air. Central sleep apnea (CSA) is caused by irregularities in the brain’s normal signals to breathe. Most people with sleep apnea will have a combination of both types. The hallmark symptom of the disorder is excessive daytime sleepiness. Additional symptoms of sleep apnea include restless sleep, loud snoring (with periods of silence followed by gasps), falling asleep during the day, morning headaches, trouble concentrating, irritability, forgetfulness, mood or behavior changes, anxiety, and depression. Not everyone who has these symptoms will have sleep apnea, but it is recommended that people who are experiencing even a few of these symptoms visit their doctor for evaluation. Sleep apnea is more likely to occur in men than women, and in people who are overweight or obese.

Is there any treatment?

There are a variety of treatments for sleep apnea, depending on an individual’s medical history and the severity of the disorder. Most treatment regimens begin with lifestyle changes, such as avoiding alcohol and medications that relax the central nervous system (for example, sedatives and muscle relaxants), losing weight, and quitting smoking. Some people are helped by special pillows or devices that keep them from sleeping on their backs, or oral appliances to keep the airway open during sleep. If these conservative methods are inadequate, doctors often recommend continuous positive airway pressure (CPAP), in which a face mask is attached to a tube and a machine that blows pressurized air into the mask and through the airway to keep it open. There are also surgical procedures that can be used to remove tissue and widen the airway. Some individuals may need a combination of therapies to successfully treat their sleep apnea.
What is the prognosis?

Untreated, sleep apnea can be life threatening. Excessive daytime sleepiness can cause people to fall asleep at inappropriate times, such as while driving. Sleep apnea also appears to put individuals at risk for stroke and transient ischemic attacks (TIAs, also known as “mini-strokes”), and is associated with coronary heart disease, heart failure, irregular heartbeat, heart attack, and high blood pressure. Although there is no cure for sleep apnea, recent studies show that successful treatment can reduce the risk of heart and blood pressure problems.
What research is being done?

The National Institute of Neurological Disorders and Stroke (NINDS) and other institutes of the National Institutes of Health (NIH) conduct research related to sleep apnea in laboratories at the NIH, and also support additional research through grants to major medical institutions across the country. Much of this research focuses on finding better ways to prevent, treat, and ultimately cure sleep disorders, such as sleep apnea.

CPAP Failure is Common. 60% of Patients Abandon CPAP and Users Average Only 4-5 Hours A Night

The following blog entry is reprint of a JANUARY 2010 press release. I am frequently asked what is the best sleep apnea treatment or what is the best CPAP machine. The best treatment for sleep apnea is not a simple question as it will vary between patients. One thin we no for certain, the best treatment is a treatment that is used. CPAP machines sitting in your closet do not constitute the best treatment. The press release below discusses the fact that the majority of patients do not use their CPAP. CPAP is not the best treatment for those patient. Dr Ira L SHAPIRA (PRESS RELEASE FOLLOWS BELOW)

CPAP is still considered the Gold Standard of treatment even though the majority of patients discontinue use. CPAP failure occurs do to lack of patient compliance not because CPAP is not effective. CPAP is very effective when used all night.

CPAP failures are common and everyone is left frustrated. Patients feel like failures because they are frequently unaware of the fact that up to 60% of patients fail CPAP. Spouses are upset and worried, their loved ones are not only disturbing their sleep with loud snoring but they are also worried about heart attacks and stokes. Patients with untreated sleep apnea have a 36% decrease in 8 year survival compared to treated patients.

Patients with untreated apnea are more likely to die in their sleep than while exercising . They have slower reaction times than someone who is legally drunk and have a sis-fold increase in motor vehicle accidents. The number one reason for CPAP failures is that patients "Hate CPAP!"

Dr Ira Shapira is a pioneer in the field of Dental Sleep Medicine who did research as a visiting assistant professor at Rush Medical School in Chicago in the 1980's. After treating patients with oral appliances for over 25 years he was very excited when the American Academy of Sleep Medicine changed their parameters of care and determined that oral appliances along with CPAP were a first line standard of care for snoring and mild to moderate apnea treatment. The AASM also said that oral appliances were an alternative to CPAP for severe apnea when patients do not tolerate CPAP.

The National Sleep Foundation the declared that "oral Appliances are a Therapy Whose Time has Come!" in SleepMatters their regular magazine.

Dr Shapira who is a Diplomate of The American Board of Dental Sleep Medicine and a member of the AASM, DOSA and the ADSM realized that even though the appliances were extremely effective many patients were still unaware of oral appliances. While more knowledgable sleep physicians were referring patients for oral appliances most patients were unaware of this option. Studies have shown that patients prefer comfortable oral appliances to CPAP when offered a choice. Dr Shapira created the website http://www.ihatecpap.com because "i HATE CPAP!" was the number one statement he heard from patients over the years when he asked why they wanted an oral appliance.

The website is extremely popular with over 10,000 individual visits a month. Thousands of patients have found out about oral appliances at the area of the site (http://www.ihatecpap.com/oral_appliance.html) on oral appliances which has photos of many appliances.

The I HATE CPAP! website has been so successful that Dr Shapira has now created a new site http://www.ihateheadaches.org that helps patients with migraines, chronic daily headaches, sinus headaches and tension headaches find help thru Neuromuscular Dentistry.

The NHLBI considers Sleep Apnea to be a TMJ disorder and published a report "CARDIOVASCULAR AND SLEEP-RELATED CONSEQUENCES OF TEMPOROMANDIBULAR DISORDERS" In their report they state " About 60-90% of cases appear to experience satisfactory resolution of symptoms with a range of interventions" This is actually better results than almost any drug regiment for treating migraines or chronic daily headaches.

Dr Barry Cooper published a paper in Cranio that describes "overwhelming relief" of TMJ symptoms and headaches after treatment with a neuromuscular dental orthotic. The I HATE Headaches! website offers help to patients tired of living in pain. TMJ disorders are often called "The Great Imposter" because there are so many symptoms such as headaches and migraines that patients do not associate with bite problems or their jaws.

An excellent resource for patients with TMJ disorders or headaches is a story in Sleep and Health Journal "SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTOR" which can be found at http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor.
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Dr Ira L Shapira is an author and section editor of Sleep and Health Journal, President of I HATE CPAP LLC, President Dato-TECH. He was a founding and certified member of the Sleep Disorder Dental Society which became the American Academy of Dental Sleep Medicine, A founding member of DOSA, the Dental Organization for Sleep Apnea. He is a Diplomate of the American Board of Dental Sleep Medicine, A Diplomat of the American Academy of Pain Management. He is a former assistant professor at Rush Medical School's Sleep Service where he did research. Dr Shapira is a consultant to sleep centers and teaches courses in Dental Sleep Medicine in his office to doctors from around the U.S. He is the Founder of I HATE CPAP LLC and http://www.ihatecpap.com Dr Shapira also holds several patents on methods and devices for the prophylactic minimally invasive early removal of wisdom teeth and collection of bone marrow and stem cells. Dr Shapira is a licensed general dentist in Illinois and Wisconsin.