Sleep Apnea is underrecognized medical problem. It leads to some significant cardiac complications and is cause for secondary hypertension

1. Sleep Apnea and its impact
on Cardiovascular System
Dr Syed Raza
MD, MRCP, FRCP, CCT , FESC, FACC, FECVI
Consultant Cardiologist
Awali Hospital
Bahrain

2. Objectives
1. Introduction to
sleep apnea
2. Impact of sleep
apnea on
cardiovascular system
3. Management
strategies

3. Objectives
• 1. Cardiovascular complications of Sleep Apnea
• 2. Factors that lead to these complications
• 3. How to manage these complications ?

5. Sleep Apnea and CV problems
1. Hypertension
2. Arrhythmia
3. CAD
4. Stroke
5. Pulmonary hypertension
6. Heart failure
7. Sudden cardiac death

7. Hypertension
Nearly half of patients with Sleep Apnea have underlying high blood pressure
Blood pressure is generally resistant to medications
Nocturnal hypertension
Presence of hypertension in addition to co-existing co-morbidities increase
the risk of CV events as well as mortality.

8. Sleep Apnea and Arrhythmia
Exact prevalence and pathophysiology is not well
known
Brady-arrhythmia : Severe bradycardia ,sinus pause, 1st
degree AV block, Mobitz Type 1- 2nd degree AV block
Tachy-arrhythmia – PVCs , SVT, AF x 5 fold , VT (non
sustained and sustained)

9. Management of arrhythmia in Sleep Apnea
CPAP
Anti-arrhythmic generally not indicated
Specific targeted therapy if electrical conduction abnormality
detected
Atrial overdrive pacing does not help and not recommended

10. CAD and Stroke
Risk of CAD increases by 30%
Risk of stroke increases by 60%
They occur prematurely
SA apnea increases the CV mortality risk

12. OSA - CAD and Stroke
1. Co-existing co-morbidities / consequence of OSA > Obesity , DM , HPN
2. AF predisposes to ischemic stroke
3. Incidence of subarachnoid hemorrhage is higher
4. Pre-dispose to fatal and non-fatal MI
5. Studies show higher incidence of revascularization in patients with OSA
6. CV mortality is higher

13. OSA - CAD and Stroke
7. Severity of OSA directly co-relate with CV
complications and mortality
8. Presence of OSA increase peri-operative (non
cardiac surgery) CV complications and CV mortality
8. OSA and its severity should be included as a risk
marker for future CV events

14. Sleep Apnea
and Heart Failure
• Sleep Apnea and Heart Failure
are inter-related
• At least 50% of patients with HF
have OSA or CSA
• Sleep apnea increases the risk of
heart failure by 140%
• The exact prevalence and
pathophysiology of HF in Sleep
Apnea is not known

15. Sleep Apnea in
HF patients:
common
preponderance
Age above 60
Male
NYHA Class III and IV
For unknown reason sleep apnea is not
commonly seen in female HF patients

16. Factors
influencing
HF in Sleep
Apnea
Associated HPN , AF
Sympathetic overdrive
Increase pre-load due to decreased intra-thoracic
pressure
Increase afterload leading to increase left ventricular
end diastolic pressure (LVeDP) and impaired LV systolic
function
Increased pulmonary artery pressure pre-dispose to right
heart failure

17. HF & SA
Heart failure and Sleep Apnea
co-exist
Central sleep apnea in HF
patients is independent risk
marker of mortality
Presence of HF and sleep apnea
together worsens mortality

19. Sudden Cardiac
Death in Sleep
Apnea
• Obstructive sleep apnea (OSA) raises the risk
of sudden cardiac death (SCD) by 300–
400% depending on the severity of OSA.
• Published reports raised the association
between OSA and SCD but not the
mechanism of SCD..

20. Severity of Sleep Apnea and Survival

21. Management
strategies
1. Weight loss
2. CPAP
3. ASV (Adaptive Servo Ventilation)
for CSA = SERVE-HF trial
4. Stimulants – Theophylline,
Acetazolamide , Amphetamine

22. CPAP and CV benefits

23. Using CPAP as management strategy

24. CPAP and CV benefits
• 1. Improve oxygenation
• 2. Reduce oxidative stress
• 3. Reduce endothelial dysfunction
• 4. Reduce pre-load and afterload by increasing intra-thoracic
pressure.
• 5. Reduce sympathetic overdrive
• 6. Reduce HPN , Arrhythmia

31. Summary
Sleep Apnea is common but often go
undiagnosed.
Sleep Apnea leads to cardiovascular
complications and adverse CV events
Once suspected, diagnosis is not difficult
Applying right management strategies can
lead to life changing as well as life saving
experience.