Obstructive Sleep Apnea Risk Factor and Complication of Stroke 10th Annual Cerebrovascular Symposium May 5, 2016 Sandeep P Khot MD Associate Professor of Neurology University of Washington School of Medicine Harborview Medical Center Seattle, Washington
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FINANCIAL DISCLOSURE: Research Grant Support: UW Institute of Translational Health Sciences Small Pilot Grant; American Sleep Medicine Foundation Focused Projects Award
Material Support: Philips Respironics—CPAP machine donations for research study
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OSA as Risk Factor for Stroke Obstructive sleep apnea (OSA) common, under-recognized stroke risk factor, with estimated prevalence 50-70%
OSA 30% more common in stroke patients; moderate-severe OSA in men with 3-fold higher risk of stroke Estimated 6% increased stroke risk per unit increase in AHI
Herman DM. Neurology 2009 Bassetti CL. Stroke 2006 Shahar E. Am J Respir Crit Care Med 2001
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OSA as Risk Factor for Stroke
HR 1.97 (1.12-3.48; p=0.01)
Yaggi HK. NEJM 2005; Munoz R. Stroke 2006
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Yaggi H. Lancet Neurol 2004
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Johnson KG. J Clin Sleep Med. 2010
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Chicken: - No link between stroke severity, topography or presumed etiology - Frequency of OSA similar with TIA and stroke Egg: - OSA improves in subacute stroke phase - -CSA, C-S respiration and positional SA improve with time (more so than OSA) Hermann DM. Neurology 2009
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CPAP Treatment after Stroke
For non-fatal cardiovascular events: HR 2.87 (CI 1.11-7.71), p=0.03 Adjusted for age, sex, BI, other cardiovascular risk factors For fatal cardiovascular events: HR 1.76 (CI 1.12-2.68), p=0.009
NNT=4.9 patients Martinez-Garcia MA. Eur Resp J. 2012
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CPAP Treatment after Stroke
50/57 vs 61/69, p=0.91
Parra O. Eur Resp J. 2011
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AHA Guidelines
Kernan W. Stroke 2014
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STOP-BANG Questionnaire 1. Snoring: do you snore loudly (loud enough to be heard through closed doors)? 2. Tired: do you often feel tired, fatigued, or sleepy during daytime? 3. Observed: has anyone observed you stop breathing during your sleep? 4. Blood pressure: do you have or are you being treated for high blood pressure? 5. BMI: BMI more than 35 kg/m2? 6. Age: age more than 50 years old? 7. Neck circumference: neck circumference greater than 40 cm? 8. Gender: male? High risk of OSA: answering yes to 3 or more items. Low risk of OSA: answering yes to fewer than 3 items. Chung F. Anesthesiology 2008
Stroke OSA predicts stroke outcome Johnson KG. J Clin Sleep Med 2010 Bassetti CL. Stroke 2006 Brown DL. Semin Neurol 2006 Kaneko Y. Sleep 2003
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OSA as Predictor of Stroke Outcome OSA may adversely affect recovery from stroke in short-term and long-term Stroke patients with OSA do not have same degree of
sleepiness as non-stroke patients and have lower BMI values Currently no guidelines on who, when or how to best screen stroke patients for OSA
Selic C. Stroke 2005; Kaneko Y. Sleep 2003 Sahlin C. Arch Intern Med 2008; Arzt M Am J Respir Crit Care 2005
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OSA as Predictor of Stroke Outcome Mean 44.6 (+/- 3.1 days) from stroke onset to PSG Multiple regression analysis: OSA significantly, independently related to functional impairment and length of hospitalization
Kaneko Y. Sleep 2003
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Tomfohr LM. Stroke. 2012
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CPAP after Acute Stroke
Ryan C. Stroke 2011
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CPAP after Acute Stroke
Ryan C. Stroke 2011
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CPAP after Acute Stroke
Auto-titrating CPAP for 3 nights from 1st night after stroke and continued for 4 more nights if AHI > 10
Minnerup J. Stroke 2012
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CPAP after Acute Stroke 21/31 within 2 days
13/15 (87%) AHI≥5
24/35 (69%) AHI≥5
13/15 (87%) AHI≥5
Bravata D. Sleep 2011
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CPAP after Acute Stroke
Khot S. J Clin Sleep Med (in press)
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On-treatment FIM Change, n=30 P=0.11 P=0.17
P=0.06
Khot S. J Clin Sleep Med (in press)
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Lesser of two evils Up to 30% prescribed CPAP refuse from onset and 25% remaining discontinue within 1 year Only 50% of non-stroke patients remain adherent long-term (4 hrs use on 70% nights-- 21/30 days) Long-term adherence determined after 3 nights of use Poor treatment adherence (12% and 15% in 2 studies) is major limitation among stroke patients due to poor CPAP tolerance Wickwire EM. Chest 2013; Stepnowsky CJ. Sleep Med. 2002; Hui DS. Chest 2002; Bassetti CL. Stroke 2006
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Patterns of CPAP adherence • Established early (1st night) and predict long-term use • Subjective and objective monitoring CPAP has been shown to be discordant • Social variables, including social support and partner’s sleep quality affect decision to adhere • Disease severity less important than symptom relief • Dose response relationship between hours of use and both health related and functional outcomes Lewis K. Sleep 2004; Kribbs N. Am Rev Respir Dis 1993; McCardle N Thorax 2001
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Weaver T. Proc Am Thorac Soc 2008
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SCOUTS 2 Aims Enroll stroke patients admitted for inpatient rehabilitation into pilot, clinical trial to identify means to maximize CPAP tolerance and adherence during inpatient rehabilitation and for a 3-month period from enrollment Assess relationship between CPAP adherence and neurological recovery using the change in the Functional Independence Measure
(FIM) at discharge and at 3 months following enrollment
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Phase 1
Active autotitrating CPAP Run-in period (nights 1-3)
90 pts Enrollment: ischemic stroke or intraparenchymal hemorrhage patients admitted to inpatient rehabilitation unit (day 0)*
*All patients referred to sleep medicine clinic after discharge
Phase 3
Phase 2
3 nights of Auto-CPAP & intensive CPAP adherence protocol
