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Author: Kristin Watson, PharmD, BCPS-AQ Cardiology

Obstructive sleep apnea (OSA) is a chronic condition where a patient has repetitive, temporary episodes in which breathing decreases or stops during sleep. This is due to narrowing or collapse of the upper airway. 1,2 These disruptions can prevent patients from having a restful night of sleep, leading to daytime sleepiness. In addition to potentially impacting a patient’s quality of life, OSA may play a role in the risk or development of several cardiac conditions. This piece will review signs and symptoms that should prompt clinicians to refer patients for OSA evaluation. The association between OSA and several cardiac conditions will also be discussed.

Who?
Risk factors for OSA include, but are not limited to, obesity (body mass index > 35 kg/m2), being a male, family history of OSA, older age, and retrognathia (lower jaw set back from top jaw). Patients with OSA can present with daytime sleepiness, cognitive impairment, and/or a mood disorder. Those with OSA may snore loudly and/or their sleeping partner may notice that the patient stops breathing or gasps for air during sleep. Nocturia has also been reported.1-3

The United States Preventive Services Task Force reported that there is insufficient evidence to screen for OSA in asymptomatic adults. Asymptomatic adults were noted to be those “not aware of their symptoms or do not report symptoms as being a concern to their clinician”.4 Some cardiac conditions can cause fatigue making it challenging to discern the potential etiology of symptoms. Therefore, careful assessment of OSA symptoms is warranted. Clinicians should be certain to evaluate for signs of OSA versus relying on symptoms alone.

How?
Several tools are available and can assist clinicians in determining if further evaluation for OSA should occur. One of the more commonly cited tools is the STOP-Bang Questionnaire (Table 1). 2,5 This is a quick and easy tool to use for any clinician, including pharmacists. Patients with a score of 5 or more are considered to be at high risk for moderate to severe OSA. It has been recommended that those with an intermediate score (i.e., 3 to 4) have further criteria applied to determine if the patient is at intermediate or high risk. For example, men with two other points on the STOP-Bang questionnaire would be considered high risk; refer to the Table for other scenarios. 5 Concern for OSA should prompt referral to a sleep disorder specialist who will then determine if a home sleep apnea study or polysomnography should be conducted.6  The results of these tests are used to diagnosis OSA.

Once a diagnosis of OSA is made, patients are typically treated with positive airway pressure. Continuous positive airway pressure (CPAP) is the most common method utilized. Weight loss is recommended for those who are overweight or obese.3 Patients should be asked about compliance with CPAP (e.g., number of hours worn each night, number of days per week device used). Reasons for noncompliance include claustrophobia and skin irritation.3 Patients should be counseled on the potential benefits of CPAP and should be referred to their sleep disorder specialist if the patient complains of challenges with using their device.

Why?
Non-cardiac complications of OSA include daytime fatigue, irritability and decreased quality of life.2,3 Treatment of OSA has been shown to improve daytime sleepiness and quality of life. Motor vehicle accidents and workplace injuries have been shown to be increased in those with OSA.7,8  A strong association has been made between OSA and various cardiac conditions.3 The presence of OSA has been shown to increase an individual’s risk of and progression of cardiovascular disease, heart failure and atrial fibrillation (AF).9-12 However, treatment of OSA has not been shown to lower the risk of death or cardiovascular events.13,14 The following highlights some associations between OSA, its treatment, and cardiac conditions. Readers are referred to the White Paper: Sleep Apnea and Cardiovascular Disease Lessons from Recent Trial and Need for Team Science for an in-depth review of these associations. 9 There are on-going trials further evaluating the impact of OSA treatment on cardiac outcomes.9

Atrial fibrillation OSA is a known risk factor for AF. Evaluation and treatment of OSA should occur when suspected in those with AF.11 Those with OSA being treated with CPAP are less likely to progress to more permanent forms of AF.

Bradycardia It is recommended that patients with conduction abnormalities or bradycardia during sleep be evaluated for sleep apnea and that the patient be treated with CPAP, if OSA is present. It is also reasonable to assess for sleep apnea in patient who already has or is being considered for a permanent pacemaker for bradycardia or a conduction disturbance.  CPAP treatment, in those diagnosed with OSA, has been shown to decrease the number of bradycardic episodes and the development of long-term symptomatic bradycardia; pacemaker implantation may also be avoided.15

Heart failure It is reasonable to assess for sleep apnea in patients with New York Heart Association class II-IV heart failure (HF) symptoms in whom a sleep disorder is suspected or excessive daytime sleepiness is reported. Central sleep apnea and OSA are common in this population. 10 Moderate to severe untreated OSA has been associated with an increased risk of death in those with HF. However, treatment with CPAP has not been shown to reduce the risk of HF events.9,12

Hypertension  OSA is an established risk factor for hypertension. Treatment of OSA with CPAP has been shown to lower systolic blood pressure by 2-3 mmHg. Screening for OSA should occur in those with resistant hypertension as OSA is prevalent in this population. 16

Did You Know?
Benzodiazepines can worsen sleep apnea and should be avoided, especially in those with untreated OSA.17

Conclusion

No matter the practice setting, clinicians can screen for the signs and symptoms of OSA. Pharmacists can play a role in identifying patients who are at risk for OSA and require testing. Additionally, pharmacists can assess adherence to CPAP and provide education on the importance of treating OSA.  Treatment of OSA can improve daytime sleepiness and may improve quality life. At this time, treatment of OSA has not been shown to improve cardiovascular morbidity and mortality. Clinicians should encourage patients with OSA to lose weight and ensure management of other cardiac risk factors.

 
Kristin Watson, PharmD, BCPS-AQ Cardiology

Dr. Watson is an associate professor in the Department of Pharmacy Practice and Science at the University of Maryland School of Pharmacy, and practices as a clinical pharmacy specialist in the ambulatory heart failure clinic at the Veterans Affairs Medical Center in Baltimore, MD. Follow her on Twitter @cards_pharm_gal

References:

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  2. Semelka M, Wilson J, Floyd R. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. American family physician 2016;94:355-60.
  3. Qaseem A, Holty J-EC, Owens DK, et al. Management of Obstructive Sleep Apnea in Adults: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine 2013;159:471-83.
  4. Force UPST. Screening for Obstructive Sleep Apnea in Adults: US Preventive Services Task Force Recommendation StatementUSPSTF Recommendation: Screening for Obstructive Sleep Apnea in AdultsUSPSTF Recommendation: Screening for Obstructive Sleep Apnea in Adults. JAMA 2017;317:407-14.
  5. Chung F, Abdullah HR, Liao P. STOP-Bang Questionnaire: A Practical Approach to Screen for Obstructive Sleep Apnea. Chest 2016;149:631-8.
  6. Kapur VK, Auckley DH, Chowdhuri S, et al. Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine 2017;13:479-504.
  7. Tregear S, Reston J, Schoelles K, Phillips B. Continuous positive airway pressure reduces risk of motor vehicle crash among drivers with obstructive sleep apnea: systematic review and meta-analysis. Sleep 2010;33:1373-80.
  8. Garbarino S, Guglielmi O, Sanna A, Mancardi GL, Magnavita N. Risk of Occupational Accidents in Workers with Obstructive Sleep Apnea: Systematic Review and Meta-analysis. Sleep 2016;39:1211-8.
  9. Drager LF, McEvoy RD, Barbe F, Lorenzi-Filho G, Redline S. Sleep Apnea and Cardiovascular Disease: Lessons From Recent Trials and Need for Team Science. Circulation 2017;136:1840-50.
  10. Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. J Card Fail 2017;23:628-51.
  11. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2019.
  12. McEvoy RD, Antic NA, Heeley E, et al. CPAP for Prevention of Cardiovascular Events in Obstructive Sleep Apnea. New England Journal of Medicine 2016;375:919-31.
  13. da Silva Paulitsch F, Zhang L. Continuous positive airway pressure for adults with obstructive sleep apnea and cardiovascular disease: a meta-analysis of randomized trials. Sleep medicine 2018;54:28-34.
  14. Abuzaid AS, Al Ashry HS, Elbadawi A, et al. Meta-Analysis of Cardiovascular Outcomes With Continuous Positive Airway Pressure Therapy in Patients With Obstructive Sleep Apnea. Am J Cardiol 2017;120:693-9.
  15. Kusumoto FM, Schoenfeld MH, Barrett C, et al. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay. A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society 2018:25701.
  16. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2017.
  17. Wang SH, Chen WS, Tang SE, et al. Benzodiazepines Associated With Acute Respiratory Failure in Patients With Obstructive Sleep Apnea. Frontiers in pharmacology 2018;9:1513.
Obstructive sleep apnea screening: what every pharmacist should know

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