Diagnosing and managing sleep apnea in patients with chronic cerebrovascular disease: a randomized trial of a home-based strategy

Abstract

BackgroundObstructive sleep apnea is common and associated with poor outcomes after stroke or transient ischemic attack (TIA). We sought to determine whether the intervention strategy improved sleep apnea detection, obstructive sleep apnea (OSA) treatment, and hypertension control among patients with chronic cerebrovascular disease and hypertension.MethodsIn this randomized controlled strategy trial intervention, patients received unattended polysomnography at baseline, and patients with OSA (apnea-hypopnea index ≥5 events/h) received auto-titrating continuous positive airway pressure (CPAP) for up to 1 year. Control patients received usual care and unattended polysomnography at the end of the study, to identify undiagnosed OSA. Both groups received 24-h blood pressure assessments at baseline and end of the study. “Excellent” CPAP adherence was defined as cumulative use of ≥4 h/night for ≥70% of the nights.ResultsAmong 225 randomized patients (115 control; 110 intervention), 61.9% (120/194) had sleep apnea. The strategy successfully diagnosed sleep apnea with 97.1% (102/105) valid studies; 90.6% (48/53, 95% CI 82.7–98.4%) of sleep apnea was undiagnosed among control patients. The intervention improved long-term excellent CPAP use: 38.6% (22/57) intervention versus 0% (0/2) control (p < 0.0001). The intervention did not improve hypertension control in this population with well-controlled baseline blood pressure: intervention, 132.7 mmHg (±standard deviation, 14.1) versus control, 133.8 mmHg (±14.0) (adjusted difference, −1.1 mmHg, 95% CI (−4.2, 2.0)), p = 0.48).ConclusionsPatients with cerebrovascular disease and hypertension have a high prevalence of OSA. The use of portable polysomnography, and auto-titrating CPAP in the patients’ homes, improved both the diagnosis and the treatment for sleep apnea compared with usual care but did not lower blood pressure.

Obstructive sleep apnea and stroke: hand in hand?

“…These differences may be due to the lower AHI cut-off (≥5 vs. >10 /hour) and the exclusion of those who received thrombolysis from other similar studies (20). This study confirms previous study findings of a very high level of undiagnosed sleep apnea (4.4% prior diagnosis of OSA) within the community (21). While the onset of OSA may be de novo post stroke most of the evidence suggests that it usually is a pre-existing condition (5).…”

Sleep Disorders in Stroke: An Update on Management

“…Most studies have suggested beneficial effects, particularly in sleepiness, depression, functional recovery, and recurrent events [69][70][71][72]. A home-based randomized trial on managing sleep apnea in chronic stroke patients showed that CPAP use at home improved OSA symptoms compared with non-use (Table 2) [73]. Two randomized controlled studies also proved that CPAP was superior to conventional therapies in terms of neurological recovery [74,75].…”

Advances in non‐invasive positive airway pressure technology

“…CSA and Cheyne–Stokes respiration (CSR) are common in patients with heart failure and may be seen following ischaemic or haemorrhagic stroke, although the prevalence is significantly less than that seen in heart failure . Sleep fragmentation arising from arousals following apnoeic events likely contribute to fatigue and sleepiness reported by patients.…”

“…CSA and Cheyne-Stokes respiration (CSR) are common in patients with heart failure 28 and may be seen following ischaemic or haemorrhagic stroke, although the prevalence is significantly less than that seen in heart failure. 29,30 Sleep fragmentation arising from arousals following apnoeic events likely contribute to fatigue and sleepiness reported by patients. Furthermore, repetitive apnoeas and arousals induce an increase in sympathetic nerve activity, which is associated with adverse physiological effects and poorer prognosis in patients with chronic heart failure (CHF).…”