By Olivia Gilbert, MD, MSc, FACC, and Andrew M. Namen, MD, FCCP, FAASM
Sleep apnea is a common but underrecognized condition. It is estimated that up to one-fourth of the world population has symptoms of sleep apnea, but only 25% of cases have been flagged and only 1 in 50 have undergone sleep testing. As a result, most patients are undiagnosed and untreated.1,2
The overall prevalence of patients at risk for sleep apnea can be considerably higher within special populations, to which some cardiopulmonary rehabilitation participants may belong. Approximately 65% of patients admitted to a cardiovascular ward service, pulmonary ward service, geriatric service, or hospitalist service are considered at risk. Patients with heart failure, recent stroke, atrial fibrillation, or advanced respiratory conditions are also more likely to have risk factors or known obstructive sleep apnea (OSA) — the most common form of the disorder, in which effort for breathing is being made in the context of reduced or no airflow.
The Importance for CR/PR Participants
As a result of these interruptions to airflow, the body experiences repetitive rises in blood pressure, heart rate changes, and declining oxygen levels. The result is inflammation within blood vessels, impaired cardiac relaxation, poor heart rhythm control, and blood thickening. Consequently, there is an increased occurrence of heart rhythm disturbance such as atrial fibrillation, heart failure decompensation, and risk of coronary disease.
Treatment of sleep apnea has been associated with improvement in the management of these conditions:
- Numerous studies demonstrate improved control of atrial fibrillation with appropriate sleep apnea management with CPAP (continuous positive airway pressure)
- Patients with reduced ejection fraction have experienced improvement in their ejection fraction, as well as fewer heart failure events and hospital admissions
- For individuals with severe heart failure who are dependent on long-term heart pumps called left ventricular assist devices, mortality rates trend lower among those with sleep apnea adherent to CPAP3,4
- Patients with ischemic heart disease have fewer events if they are receiving CPAP to treat their sleep apnea
Recognizing the Signs…and Realizing the Savings
Cardiopulmonary rehab has been shown to reduce the severity of OSA, especially among those with coronary disease, and it is important that CR/PR professionals recognize red flags for the disorder in their participants. A number of nocturnal symptoms are helpful in identifying patients who are potentially at risk, including the presence of snoring, witnessed apnea by a bed partner, choking or gasping during slumber, and multiple nighttime arousals. These symptoms — in addition to certain physical exam findings, such as body mass index greater than 32 and neck circumference greater than 16 inches for females or 17 inches for male — have been incorporated into sleep questionnaires to help identify vulnerable patients. Validated queries such as DOISNORE50, STOP-BANG, and the Berlin Questionnaire are applicable on both an inpatient and outpatient basis to identify at-risk individuals.5,6
Because of the benefit and impact to recovery, patients in cardiac rehab should be screened for OSA whether they are in the post-recovery or prehabilitation stage of care. By identifying such patients, some health systems have incorporated protocols to ensure patient safety following elective or nonelective admissions. In fact, patients who are screened compared with those who are not screened tend to have better outcomes in terms of avoiding major events within the hospital system — such as a CODE BLUE, reintubation, or activation of a safety team — that prolong duration of stay and/or time in the ICU.7
Recently, data has been reported suggesting that undergoing sleep apnea screening also can reduce hospitalization costs, particularly among patients with heart conditions.8,9 Among approximately 15,000 patients with atrial fibrillation, heart failure, or admission to a cardiovascular surgical unit, sleep apnea screening with DOISNORE50 was associated with fewer hospital days, fewer ICU days, and overall reduced cost (by about $37,000) vs. no screening. Those who underwent screening at Atrium Health Wake Forest were entered into a sleep safety protocol in which electronic medical record alerts, treatment with CPAP therapy, and sleep consultation were recommended and provided.8
Unfortunately, a significant number of patients do not utilize CPAP therapy as recommended. Several large studies have demonstrated that when a patient uses therapy less than recommended at approximately 3.5 hours, cardiovascular benefit is not realized. However, the comprehensive role of the therapist is key. Studies suggest that therapist education and knowledge shared with the patient can result in better outcomes. Informing the patient of the impact of high-intensity exercise; weight-loss strategies, including the recently approved GLP1 medications; and ways to improve CPAP compliance can all contribute to better OSA control.
THE AUTHORS:
Olivia Gilbert, MD, MSc, FACC
Associate Professor, Wake Forest Baptist Medical Center
Director of Quality and Value for Cardiovascular Medicine
Department of Cardiovascular Medicine
Advanced Heart Failure, Heart Transplant, and Mechanical Circulatory Support
Andrew M. Namen, MD, FCCP, FAASM
Professor of the Department of Internal Medicine, Pediatrics, and Otolaryngology
Medical Director of Atrium Health Wake Forest Sleep Medicine Program
REFERENCES:
1Heinzer R, Vat S, Marques-Vidal P, et al. Prevalence of sleep-disordered breathing in the general population: the HypnoLaus study. Lancet Respir Med. 2015;3(4):310-318. doi:10.1016/S2213-2600(15)00043-
2Veasey SC, Rosen IM. Obstructive sleep apnea in adults. N Engl J Med. 2019;380(15):1442-1449. doi:10.1056/NEJMcp1816152
3Schaffer SA; Bercovitch RS; Ross HJ; Rao V. Central Sleep apnea interfering with adequate left ventricular fi lling in a patient with left ventricular assist device. J Clin Sleep Med 2013;9(2):161-162
4Carlquist et al.THE ROLE OF OBSTRUCTIVE SLEEP APNEA IN PATIENTS WITH NEWLY IMPLANTED LEFT VENTRICULAR ASSIST DEVICESACC April 2, 2024 Volume 83, Issue 13, Suppl A (poster)
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7Namen AM, Forest D, Saha AK, Xiang KR, Younger K, Stephens SEE, Maurer S, Chatterjee AB, Sy A, O'Donovan C, Kumar S, Pinyan C, Carroll R, Peters SP, Haponik EF. Reduction in medical emergency team activation among postoperative surgical patients at risk for undiagnosed obstructive sleep apnea. J Clin Sleep Med. 2022 May 2. doi: 10.5664/jcsm.10032
8Xiang KR, Sheehan https://pubmed.ncbi.nlm.nih.gov/39101404/ KN, Saha AK, Koch AL, Rackley J , Hicklin H, Ghatak RL, Bhave P, Fakharian A, Gilbert ON, Forest DJ, Kirsch DB , Younger K, Haponik EF, https://pubmed.ncbi.nlm.nih.gov/?term=Peters+SP&cauthor_id=39101404 Peters SP, Namen AM.. Medical emergency team activation and cost reduction in cardiovascular surgery and nonsurgical patients: DOISNORE50 sleep protocol. Sleep. 2024. PMID: 39101404 DOI: 10.1093
9Saha AK, Sheehan KN, Xiang KR, Rackley J, Hicklin H, Koch AL, Bhave PD, Forest DJ, Kirsch DB, Ghatak R, Haponik EF, Peters SP, Namen AM. Preoperative sleep apnea screening protocol reduces medical emergency team activation in patients with atrial fibrillation. J Clin Sleep Med. 2024 May 1;20(5):783-792. doi: 10.5664/jcsm.1100