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.
Highlights
Obstructive sleep apnea is found in at least half of individuals who have experienced an acute stroke or transient ischemic attack (TIA) [1,2,3,4,5,6,7,8,9]
When restricting the analysis to intervention patients with sleep apnea, no difference in the change in mean 24-h systolic blood pressure was identified for patients with excellent (−1.1 mmHg) versus not excellent (−1.1 mmHg) continuous positive airway pressure (CPAP) adherence (Table 5). Both final and change in medicationadjusted 24-h SBP favored the excellent use group, but the difference between mean final medication adjusted SBP was not statistically significant. These results demonstrate that sleep apnea is very common among patients with chronic cerebrovascular disease and hypertension; the observed prevalence of 120/194 (62%) is similar to rates observed in studies that have primarily focused on acute and subacute cerebrovascular disease populations [1,2,3,4,5,6,7,8,9]
These results demonstrate that a strategy of diagnosing and treating sleep apnea in the homes of patients with chronic cerebrovascular disease and hypertension can lead to substantial improvements in the detection of sleep apnea and in treatment with CPAP
Summary
Obstructive sleep apnea is found in at least half of individuals who have experienced an acute stroke or transient ischemic attack (TIA) [1,2,3,4,5,6,7,8,9]. Sleep apnea has been associated with a variety of adverse disease states and outcomes including hypertension, diabetes, ischemic stroke and transient ischemic attacks (TIA), incident coronary events and cardiovascular mortality, and all-cause mortality [3, 10,11,12,13,14]. The American Heart Association/American Stroke Association secondary stroke prevention guidelines recommend that patients with ischemic stroke and TIA receive screening for sleep apnea and treatment because of data suggesting that post-cerebrovascular event patient outcomes are improved with treatment of sleep apnea [16]. Obstructive 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
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