Several articles detailing increased risk of stroke in patients with sleep apnea and worse medical outcomes have recently been published (see PubMed abstracts below).
One article "Worse Outcome after Stroke in Patients with Obstructive Sleep Apnea: An Observational Cohort Study." suggests that patients who have had strokes should be screened for apnea and patients with sleep apnea are at an increased risk of death. "Our findings suggest that patients considered at high risk for ischemic stroke should be screened for OSA, the prevalence of which may be as high as 60%. Those with definitive diagnosis of OSA before stroke are at increased risk of death within the first month after an acute ischemic stroke."
A second article "Is obstructive sleep apnea an independent risk factor for stroke? A critically appraised topic" concluded that "OSA independently contributes to stroke risk."
These articles show both the danger of sleep apnea and emphasize the fact that treatment is very important. It is also known that the majority of patients abandon CPAP. The best treatment for sleep apnea in patients at risk for strokes or with a history of strokes is one that is used nightly. Recent studies have shown the majority of CPAP users abandon CPAP use. I make the case that the best treatment for sleep apnea is one that is used, hopefully all night every night.
Medicare has recognized the fact that the majority of patients do not continue to use CPAP. They have set standards for minimal usage for medicare reimbursement.
If the majority of patients abandon CPAP, what is the best treatment for obstructive sleep apnea.
My opinion, is that oral appliances are the best treatment because a vast majority of patients prefer them to CPAP. Oral appliances are not perfect and do have problems and drawbacks. There is no question that if an oral appliance successfully treats sleep apnea it is a better treatment than a CPAP machine sitting in the closet.
Morbidly obese patients are the patients who will usually find cpap the most effective treatment. Younger thinner healthier patients who do not use CPAP swhould consider oral appliances the best alternative treatment to CPAP.
Expert Rev Neurother. 2010 Aug;10(8):1267-71.
Risk of stroke from sleep apnea in men and women.
Djonlagic I, Malhotra A.
Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
Am J Respir Crit Care Med. 2010 Jul 15;182(2):269-77.
Obstructive sleep apnea (OSA) is a common sleep disorder, and research on the effects of sleep apnea is important to gain insight into how sleep affects health. Untreated OSA has been associated with important health consequences, such as an increased risk for hypertension, cardiovascular disease and diabetes. Previous studies have shown that OSA also represents a risk factor for stroke. The relationship between OSA and stroke is particularly relevant, as stroke is the second leading cause of death globally. The reviewed article presents new data from the Sleep Heart Health Study, a longitudinal cohort study, which shows an association between incident stroke and untreated OSA of varying severity for men and possibly more severe OSA for women. The study is discussed in the context of the current state of knowledge about OSA, in particular its health consequences, and the general limitations in conducting research with OSA patients.
PMID: 20662752 [PubMed - in process]
J Stroke Cerebrovasc Dis. 2010 Jul 24. [Epub ahead of print]
Worse Outcome after Stroke in Patients with Obstructive Sleep Apnea: An Observational Cohort Study.
Mansukhani MP, Bellolio MF, Kolla BP, Enduri S, Somers VK, Stead LG.
Department of Family Medicine, Mayo Clinic, Rochester, Minnesota.
To evaluate the risk and presence of obstructive sleep apnea (OSA) in patients presenting with acute ischemic stroke, and examine the correlation of OSA with age, sex, ischemic stroke subtype, disability, and death, a prospective cohort study was conducted in all consecutive patients presenting with acute ischemic stroke between June 2007 and March 2008. Exclusion criteria were age <18 years, refusal of consent for the study, and incomplete questionnaire. The Berlin Sleep Questionnaire was used to identify patients at high risk for OSA. A total of 174 patients with acute ischemic stroke were included; 130 (74.7%) had a modified Rankin Scale (mRS) score >/=3 at dismissal, and 11 patients (6.3%) died within 1 month. The Berlin Sleep Questionnaire identified 105 patients (60.4%) at high risk for OSA, along with 7 patients (4%) with a previous diagnosis of OSA. Those with a previous diagnosis of OSA were more likely to die within the first month after stroke (relative risk, 5.3; 95% confidence interval, 1.4-20.1) compared with those without OSA. Patients at high risk for OSA did not demonstrate increased mortality at 30 days (P = 1.0). In multivariate analysis, after adjusting for age and National Institutes of Health Stroke Scale score, previous diagnosis of OSA was an independent predictor of worse functional outcome, that is, worse mRS score at hospital discharge (P = .004). The mRS score was 1.2 points higher (adjusted R(2), 40%) in those with OSA. Our findings suggest that patients considered at high risk for ischemic stroke should be screened for OSA, the prevalence of which may be as high as 60%. Those with definitive diagnosis of OSA before stroke are at increased risk of death within the first month after an acute ischemic stroke.
PMID: 20656506 [PubMed - as supplied by publisher]
Neurologist. 2010 Jul;16(4):269-73.
Is obstructive sleep apnea an independent risk factor for stroke? A critically appraised topic.
Capampangan DJ, Wellik KE, Parish JM, Aguilar MI, Snyder CR, Wingerchuk D, Demaerschalk BM.
Department of Neurology, Mayo Clinic, Scottsdale, AZ, USA.
BACKGROUND: Obstructive sleep apnea (OSA) is associated with hypertension, atrial fibrillation, coronary artery disease, congestive heart failure, and diabetes. These disorders are also risk factors for stroke.
OBJECTIVE: To determine whether OSA increases the risk of stroke independently of other cerebrovascular risk factors.
METHODS: The objective was addressed through the development of a structured critically appraised topic. This evidence-based methodology included a clinical scenario, structured question, search strategy, critical appraisal, results, evidence summary, commentary, and bottom line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and content experts in the field of sleep medicine and vascular neurology.
RESULTS: A large observational cohort study was selected and appraised to address this prognostic question. The unadjusted analysis revealed that OSA (apnea-hypopnea index >5) was associated with stroke or death from any cause (hazard ratio, 2.24; 95% confidence interval [CI], 1.30-3.86; P = 0.004). The adjusted OSA analysis retained a statistically significant association with stroke or death (hazard ratio, 1.97; 95% CI, 1.12-3.48; P = 0.01). In separate unadjusted analyses, OSA was associated with death and stroke with relative risks of 1.68 (95% CI, 1.10-2.25) and 5.16 (95% CI, 3.72-6.60), respectively.
CONCLUSIONS: OSA independently contributes to stroke risk.
PMID: 20592572 [PubMed - in process]