Obstructive sleep apnoea and stroke

Recent publications. Obstructive sleep apnoea and stroke. Issue 3, January 2012 With an introduction by Alain Lurie, MD Linde: Living healthcare 0...
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Recent publications.

Obstructive sleep apnoea and stroke. Issue 3, January 2012 With an introduction by Alain Lurie, MD

Linde: Living healthcare

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Contents

Contents

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Contents. Obstructive sleep apnoea and stroke. 04

Introduction. Alain Lurie.



References.

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al. Stroke. 2011 Feb; 42(2): 517-84. Epub 2010 Dec 2. Erratum in Stroke. 2011 Feb; 42(2): e26.

15 Management of sleep disorders in stroke. Im KB, Strader S, Dyken ME. Curr Treat Options Neurol. 2010 Sep; 12(5): 379-95.

Abstracts referred to in the summary paper by Alain Lurie.

Other recent abstracts published in 2011.





17 Obstructive sleep apnea syndrome and cardiovascular diseases. Fava C, Montagnana M, Favaloro EJ, Guidi GC, Lippi G. SeminThrombHemost. 2011 Apr; 37(3): 280-97. Epub 2011 Mar 31.



18 Positional therapy in ischemic stroke patients with obstructive sleep apnea. Svatikova A, Chervin RD, Wing JJ, Sanchez BN, Migda EM, Brown DL. Sleep Med. 2011 Mar; 12(3): 262-6.



19 Obstructive sleep apnea and the risk for cardiovascular disease. Kohli P, Balachandran JS, Malhotra A. CurrAtheroscler Rep. 2011 Apr; 13(2): 138-46.



12 Early treatment of obstructive apnoea and stroke outcome: a randomised controlled trial. Parra O, Sanchez-Armengol A, Bonnin M, Arboix A, Campos-Rodriguez F, Perez-Ronchel J, et al. EurRespir J. 2011 May; 37(5): 1128-36. Epub 2010 Sep 16.

20 Validity of the Berlin Questionnaire in identifying obstructive sleep apnea syndrome when administered to the informants of stroke patients. Srijithesh PR, Shukla G, Srivastav A, Goyal V, Singh S, Behari M. J ClinNeurosci. 2011 Mar; 18(3): 340-3. Epub 2011 Jan 14.



13 Dissociation of obstructive sleep apnea from hypersomnolence and obesity in patients with stroke. Arzt M, Young T, Peppard PE, Finn L, Ryan CM, Bayley M, Bradley TD. Stroke. 2010 Mar; 41(3): e129-34. Epub 2010 Jan 14.

21 Nocturia is an independent predictor of severe obstructive sleep apnea in patients with ischemic stroke. Chen CY, Hsu CC, Pei YC, Yu CC, Chen YS, Chen CL. J Neurol. 2011 Feb; 258(2): 189-94. Epub 2010 Aug 21.



22 Worse outcome after stroke in patients with obstructive sleep apnea: an observational cohort study. Mansukhani MP, Bellolio MF, Kolla BP, Enduri S, Somers VK, Stead LG. J Stroke Cerebrovasc Dis. 2011 Sep-Oct; 20(5): 401-5. Epub 2010 Jul 24.

08 Sleep apnea in patients with transient ischemic attack and minor stroke: opportunity for risk reduction of recurrent stroke? Chan W, Coutts SB, Hanly P. Stroke. 2010 Dec; 41(12): 2973-5. Epub 2010 Oct 21.

09 Obstructive sleep apnea-hypopnea and incident stroke: the sleep heart health study. Redline S, Yenokyan G, Gottlieb DJ, Shahar E, O‘Connor GT, Resnick HE, Diener-West M, Sanders MH, Wolf PA, Geraghty EM, Ali T, Lebowitz M, Punjabi NM. Am J Respir Crit Care Med. 2010 Jul 15;182(2):269-77. Epub 2010 Mar 25.



10 Frequency of sleep apnea in stroke and TIA patients: a meta-analysis. Johnson KG, Johnson DC. J Clin Sleep Med. 2010 Apr 15; 6(2): 131-7.



11 Influence of continuous positive airway pressure on outcomes of rehabilitation in stroke patients with obstructive sleep apnea. Ryan CM, Bayley M, Green R, Murray BJ, Bradley TD. Stroke. 2011 Apr; 42(4): 1062-7. Epub 2011 Mar 3.







14 Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/ American Stroke Association. Goldstein LB, Bushnell CD, Adams RJ, Appel LJ, Braun LT, Chaturvedi S, et

16 Echocardiographic findings in ischemic stroke patients with obstructive sleep apnea. Svatikova A, Jain R, Chervin RD, Hagan PG, Brown DL. Sleep Med. 2011 Aug; 12(7): 700-3.

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Introduction

Introduction

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Obstructive sleep apnoea and stroke. Introduction.

Epidemiological, longitudinal, and therapeutic studies have produced convincing evidence that obstructive sleep apnoea (OSA) is associated with an increased risk of stroke, but the causal link remains unknown [1]. Methodological biases have made the interpretation of studies assessing the relationship between OSA and stroke difficult. These biases include the presence of confounders, short study duration, inadequately powered studies, and uncontrolled studies.

Alain Lurie, MD Laboratoire du Sommeil, Centre Médico-Chirurgical Ambroise Paré, Neuilly sur Seine, France

Prevalence and risk of OSA in stroke patients OSA is common among patients with transient ischaemic attack or stroke, with a prevalence of >50% [2-4]. Observational population studies have shown that OSA independently increased the risk of stroke by 1.6 to 4.3-fold [5, 6]. In a longitudinal analysis of 1,189 subjects from the general population [6], patients with an apnoea-hypopnoea index (AHI) ≥ 20 events·h-1 had a 4.3-fold increased risk of suffering a first-ever stroke over the next 4 years (p = 0.02). However, after adjustment for confounders, the odds ratio (OR) was no longer significant. The effects of OSA on the incidence of stroke, acute myocardial infarction, and death were assessed in a 10-year follow-up study of 392 patients with angina pectoris [7]. Compared to patients without sleep apnoea, patients with an AHI ≥ 5 had an ~3-fold increase in the risk of stroke, independent of confounding variables. Longitudinal analysis of 5,422 subjects without a history of stroke at baseline, who were untreated for sleep apnoea and followed for a median of 8.7 years, demonstrated that men with moderately severe sleep apnoea had a 2.86-fold higher risk of ischaemic stroke, after adjusting for confounders, than men in the lowest sleep apnoea quartile [8]. In women, stroke was not significantly associated with obstructive AHI (OAHI) quartiles, but an increased risk of stroke was observed at an OAHI > 25. A meta-

Alain Lurie, MD

analysis confirmed that OSA is very common in stroke and transient ischaemic attack patients (2,343 patients, 29 studies) [9]. The frequency of sleep-disordered breathing (SDB) with an AHI > 5 was 72% and 38% for an AHI > 20. Only 7% of the SDB was primarily central apnoea. Effects of OSA on stroke outcome OSA is an independent predictor of worse functional outcome, increased duration of post-stroke hospitalisation and rehabilitation, and increased risk of death or new vascular events [2, 3, 10]. Continuous positive airway pressure (CPAP) treatment in stroke patients with OSA is associated with decreased nocturnal blood pressure and improvement in well-being [11] and in functional and motor— but not neurocognitive—outcomes [12]. Stroke patients with OSA (AHI ≥ 20) who could not tolerate CPAP had a higher risk of new vascular events (especially another stroke) than those who tolerated the treatment (36.1 vs 6.7%, respectively; p = 0.03) in an 18-month followup study [10]. The mortality rate was not significantly different between these 2 groups. When this study was expanded and extended to 5 years of prospective observations, it was suggested that CPAP may reduce mortality in patients with moderate-to-severe OSA and ischaemic stroke [13]. Notably, there was a low percentage of adherence to CPAP among these

patients (~30%), and the comparison between patients who did and did not tolerate CPAP introduced a selection bias as these groups may be different in terms of health risks and behaviour. A 2-year follow-up randomised controlled study of ischaemic stroke patients with OSA assessed the impact of CPAP administration (N = 71) versus conventional treatment (N = 69) [14]. The percentage of patients with neurological improvement at 1 month after stroke was significantly higher in the CPAP group. The mean time until the appearance of cardiovascular events was longer in the CPAP group (14.9 vs 7.9 months, respectively; p = 0.044), although cardiovascular event-free survival after 24 months was similar in both groups. Compliance with CPAP is poor in OSA patients with stroke compared to OSA patients without stroke [15, 16]. However, 70.5% of stroke patients continued CPAP treatment at home, whereas 29.5% rejected it [11]; non-acceptance was associated with a lower functional status and aphasia. Characteristic clinical features of OSA in stroke patients: diagnosis of OSA in the poststroke period The presence of symptoms such as snoring, sleepiness, and witnessed apnoeas in stroke patients may increase their risk of having OSA; however, a significant number of patients may

be missed if history alone is used for diagnosis [9, 17]. A meta-analysis revealed that the frequency of SDB was high in stroke patients, despite a relatively low average body mass index (26.4 kg·m-2), and >25% of patients with SDB did not snore, while >50% of patients without SDB did snore [9]. Most patients at high risk for recurrent stroke do not have the typical clinical features of OSA, e.g. obesity and daytime sleepiness. Conclusion The published data show that OSA is associated with an increased risk of stroke, but the causal link remains to be demonstrated. Guidelines recommend the assessment of OSA in stroke patients (particularly in those with abdominal obesity, hypertension, heart disease, or drug-resistant hypertension) and to consider CPAP therapy when necessary [18]. Some authors consider that evaluating SDB may be warranted in all stroke patients [9, 19]; however, others believe it should only be evaluated in those who may potentially accept CPAP treatment [20].

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References

References

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References.

1. Lurie A, Cardiovascular disorders associated with obstructive sleep apnea. In: Lurie A, editor. Obstructive sleep apnea Relationship with cardiovascular and metabolic disorders. Basel: Karger; 2011. p. 199-265.

4. Chan W, Coutts SB, Hanly P. Sleep apnea in patients with transient ischemic attack and minor stroke: opportunity for risk reduction of recurrent stroke? Stroke. 2010 Dec; 41(12): 2973-2975. See page 08.

2. Parra O, et al. Time course of sleep-related breathing disorders in first-ever stroke or transient ischemic attack. Am J Respir Crit Care Med. 2000 Feb; 161(2 Pt 1): 375-380.

5. Shahar E, Whitney CW, Redline S, Lee ET, Newman AB, Javier Nieto F, et al. Sleepdisordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med. 2001 Jan; 63(1): 19-25.

3. Sahlin C, Sandberg O, Gustafson Y, Bucht G, Carlberg B, Stenlund H, et al. Obstructive sleep apnea is a risk factor for death in patients with stroke: a 10-year followup. Arch Intern Med. 2008 Feb 11; 168(3): 297-301.

6. Arzt M, Young T, Finn L, Skatrud JB, Bradley TD. Association of sleep-disordered breathing and the occurrence of stroke. Am J Respir Crit Care Med. 2005 Dec 1; 172(11): 1447-1451. 7. Valham F, Mooe T, Rabben T, Stenlund H, Wiklund U, Franklin KA. Increased risk of stroke in patients with coronary artery disease and sleep apnea: a 10-year followup. Circulation. 2008 Aug 26; 118(9): 955960.

8. Redline S, Yenokyan G, Gottlieb DJ, Shahar E, O’Connor GT, Resnick HE, et al. Obstructive sleep apnea-hypopnea and incident stroke: the sleep heart health study. Am J Respir Crit Care Med. 2010 Jul 15; 182(2): 269-277. See page 09.

11. Wessendorf TE, Wang YM, Thilmann AF, Sorgenfrei U, Konietzko N, Teschler H. Treatment of obstructive sleep apnoea with nasal continuous positive airway pressure in stroke. Eur Respir J. 2001 Oct; 18(4): 623-629.

14. Parra O, Sanchez-Armengol A, Bonnin M, Arboix A, Campos-Rodriguez F, PerezRonchel J, et al. Early treatment of obstructive apnoea and stroke outcome: a randomised controlled trial. Eur Respir J. 2011 May; 37(5): 1128-1136. See page 12.

9. Johnson KG, Johnson DC. Frequency of sleep apnea in stroke and TIA patients: a meta-analysis. J Clin Sleep Med. 2010 Apr 15; 6(2): 131-137. See page 10.

12. Ryan CM, Bayley M, Green R, Murray BJ, Bradley TD. Influence of continuous positive airway pressure on outcomes of rehabilitation in stroke patients with obstructive sleep apnea. Stroke. 2011 Apr; 42(4): 1062-1067. See page 11.

15. Bassetti CL, Milanova M, Gugger M. Sleepdisordered breathing and acute ischemic stroke: diagnosis, risk factors, treatment, evolution, and long-term clinical outcome. Stroke. 2006 Apr; 37(4): 967-972.

10. Martinez-Garcia MA, Galiano-Blancart R, Roman-Sanchez P, Soler-Cataluna JJ, Cabero-Salt L, Salcedo-Maiques E. Continuous positive airway pressure treatment in sleep apnea prevents new vascular events after ischemic stroke. Chest. 2005 Oct; 128(4): 2123-2129.

13. Martinez-Garcia MA, Soler-Cataluna JJ, Ejarque-Martinez L, Soriano Y, RomanSanchez P, Illa FB, et al. Continuous positive airway pressure treatment reduces mortality in patients with ischemic stroke and obstructive sleep apnea: a 5-year followup study. Am J Respir Crit Care Med. 2009 Jul 1; 180(1): 36-41.

16. Palombini L, Guilleminault C. Stroke and treatment with nasal CPAP. Eur J Neurol. 2006 Feb; 13(2): 198-200. 17. Arzt M, Young T, Peppard PE, Finn L, Ryan CM, Bayley M, Bradley TD. Dissociation of obstructive sleep apnea from hypersomnolence and obesity in patients with stroke. Stroke. 2010 Mar; 41(3): e129-134. See page 13.

18. Goldstein LB, Bushnell CD, Adams RJ, Appel LJ, Braun LT, Chaturvedi S, et al. Guidelines for the Primary Prevention of Stroke. A Guideline for Healthcare Professionals From the American Heart Association/ American Stroke Association. Stroke. 2011 Dec 6; 42(2): 514-582. See page 14. 19. Im KB, Strader S, Dyken ME. Management of sleep disorders in stroke. Curr Treat Options Neurol. 2010 Sep; 12(5): 379-395. See page 15. 20. Hermann DM, Bassetti CL. Sleep-related breathing and sleep-wake disturbances in ischemic stroke. Neurology. 2009 Oct 20; 73(16): 1313-1322.

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Abstracts

Abstracts

Abstract. Sleep apnea in patients with transient ischemic attack and minor stroke: opportunity for risk reduction of recurrent stroke?

Abstract. Obstructive sleep apnea-hypopnea and incident stroke: the sleep heart health study.

Chan W, Coutts SB, Hanly P.

Redline S, Yenokyan G, Gottlieb DJ, Shahar E, O‘Connor GT, Resnick HE, Diener-West M, Sanders MH, Wolf PA, Geraghty EM, Ali T, Lebowitz M, Punjabi NM.

Calgary Stroke Program, Faculty of Medicine, University of Calgary, Alberta, Canada. [email protected] Stroke. 2010 Dec; 41(12): 2973-5. Epub 2010 Oct 21.

BACKGROUND AND PURPOSE: Patients with TIA and minor stroke are at high risk for recurrent stroke. Obstructive sleep apnea (OSA) may increase this risk. The objectives of our study were to determine the prevalence and severity of OSA and its clinical presentation in this population. METHODS: Patients who presented with TIA and minor stroke completed a questionnaire and nocturnal cardiopulmonary monitoring to diagnose OSA and associated nocturnal hypoxia. RESULTS: Sixty-six patients completed the study; 62% had OSA (respiratory disturbance index > 5). Forty-four percent of these patients had moderate or severe OSA (respiratory disturbance index > 15) that was associated

with significant nocturnal hypoxia. Most patients did not have the typical clinical features of OSA, such as obesity and daytime sleepiness. CONCLUSIONS: Patients who experience TIA and minor stroke have a high prevalence of OSA and associated hypoxia. The atypical clinical presentation of OSA in this patient population may lead to under-recognition and treatment. Further studies are required to determine the impact of treating OSA on the risk of recurrent stroke.

Comment in Stroke. 2011 May; 42(5): e374. PMID: 20966412 [PubMed - indexed for MEDLINE]

Brigham and Women‘s Hospital, 221 Longwood Ave., Boston, MA 02115M, USA. [email protected] Am J Respir Crit Care Med. 2010 Jul 15;182(2):269-77. Epub 2010 Mar 25.

RATIONALE: Although obstructive sleep apnea is associated with physiological perturbations that increase risk of hypertension and are proatherogenic, it is uncertain whether sleep apnea is associated with increased stroke risk in the general population. OBJECTIVES: To quantify the incidence of ischemic stroke with sleep apnea in a communitybased sample of men and women across a wide range of sleep apnea. METHODS: Baseline polysomnography was performed between 1995 and 1998 in a longitudinal cohort study. The primary exposure was the obstructive apnea-hypopnea index (OAHI) and outcome was incident ischemic stroke. MEASUREMENTS AND MAIN RESULTS: A total of 5,422 participants without a history of stroke at the baseline examination and untreated for sleep apnea were followed for a median of 8.7 years. One hundred ninety-three ischemic strokes were observed. In covariate-adjusted Cox proportional hazard models, a significant positive association between ischemic stroke and OAHI was observed in men (P value for linear trend: P = 0.016). Men in the highest

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OAHI quartile (>19) had an adjusted hazard ratio of 2.86 (95% confidence interval, 1.1-7.4). In the mild to moderate range (OAHI, 5-25), each one-unit increase in OAHI in men was estimated to increase stroke risk by 6% (95% confidence interval, 2-10%). In women, stroke was not significantly associated with OAHI quartiles, but increased risk was observed at an OAHI greater than 25. CONCLUSIONS: The strong adjusted association between ischemic stroke and OAHI in community-dwelling men with mild to moderate sleep apnea suggests that this is an appropriate target for future stroke prevention trials.

Comment in Am J Respir Crit Care Med. 2010 Nov 15; 182(10): 1332; author reply 1332-3. Expert Rev Neurother. 2010 Aug; 10(8): 126771. Am J Respir Crit Care Med. 2010 Nov 15; 182(10): 1332; author reply 1332-3. Am J Respir Crit Care Med. 2011 Apr 1; 183(7): 950; author reply 950. PMID: 20339144 [PubMed - indexed for MEDLINE] PMCID: PMC2913239 Free PMC Article

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Abstracts

Abstracts

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Abstract. Frequency of sleep apnea in stroke and TIA patients: a meta-analysis.

Abstract. Influence of continuous positive airway pressure on outcomes of rehabilitation in stroke patients with obstructive sleep apnea.

Johnson KG, Johnson DC.

Ryan CM, Bayley M, Green R, Murray BJ, Bradley TD.

Department of Neurology, Baystate Medical Center Springfield, MA 01199, USA. [email protected] J Clin Sleep Med. 2010 Apr 15; 6(2): 131-7.

STUDY OBJECTIVES: To determine the frequency of sleep disordered breathing (SDB) in ischemic and hemorrhagic stroke and transient ischemic attack (TIA) patients by metaanalysis. METHODS: A systematic literature search using Medline, EMBASE and CINAHL and a manual review of references through December 2008 was conducted using specific search terms. The frequency of SDB stratified by apnea hypopnea index (AHI) was extracted by the author. Weighted averages using a randomeffects model are reported with 95% confidence intervals. RESULTS: Twenty-nine articles evaluating patients with autoCPAP, limited-channel sleep study, or full polysomnography were included in this study. In meta-analysis of 2,343 ischemic or hemorrhagic stroke and TIA patients, the frequency of SDB with AHI > 5 was 72% and with AHI > 20 was 38%. Only 7% of the SDB was primarily central apnea. There was no significant difference in SDB prevalence

by event type, timing after stroke, or type of monitoring. Males had a higher percentage of SDB (AHI > 10) than females (65% compared to 48% p = 0.001). Patients with recurrent strokes had a higher percentage of SDB (AHI > 10) than initial strokes (74% compared to 57% p = 0.013). Patients with unknown etiology of stroke had a higher and cardioembolic etiology a lower percentage of SDB than other etiologies. CONCLUSIONS: SDB is very common in stroke patients irrespective of type of stroke or timing after stroke and is typically obstructive in nature. Since clinical history alone does not identify many patients with SDB, sleep studies should be considered in all stroke and TIA patients.

Comment in J Clin Sleep Med. 2010 Apr 15; 6(2): 138-9. PMID: 20411688 [PubMed - indexed for MEDLINE] PMCID: PMC2854698 Free PMC Article

Toronto Rehabilitation Institute, University of Toronto, Ontario, Canada [email protected] Stroke. 2011 Apr; 42(4): 1062-7. Epub 2011 Mar 3.

BACKGROUND AND PURPOSE: In stroke patients, obstructive sleep apnea (OSA) is associated with poorer functional outcomes than in those without OSA. We hypothesized that treatment of OSA by continuous positive airway pressure (CPAP) in stroke patients would enhance motor, functional, and neurocognitive recovery. METHODS: This was a randomized, open label, parallel group trial with blind assessment of outcomes performed in stroke patients with OSA in a stroke rehabilitation unit. Patients were assigned to standard rehabilitation alone (control group) or to CPAP (CPAP group). The primary outcomes were the Canadian Neurological scale, the 6-minute walk test distance, sustained attention response test, and the digit or spatial span-backward. Secondary outcomes included Epworth Sleepiness scale, Stanford Sleepiness scale, Functional Independence measure, Chedoke McMaster Stroke assessment, neurocognitive function, and Beck depression inventory. Tests were performed at baseline and 1 month later. RESULTS: Patients assigned to CPAP (n=22) experienced no adverse events. Regarding

primary outcomes, compared to the control group (n=22), the CPAP group experienced improvement in stroke-related impairment (Canadian Neurological scale score, P