Obstructive Sleep Apnea In Stroke Patients Research Articles

Sex Differences in Obstructive Sleep Apnea after Stroke.

Obstructive sleep apnea (OSA) is prevalent after stroke and associated with recurrent stroke, prolonged hospitalization, and decreased functional recovery. Sex differences in post-stroke OSA remain underexplored. The objective of this study was to evaluate sex differences in functional outcomes, stroke and OSA severity, and clinical manifestations of OSA in stroke patients with OSA. We retrospectively evaluated data from three previously conducted studies. Study patients had an imaging-confirmed stroke and had been found to have OSA (apnea-hypopnea index [AHI] ≥ 5) on either in-laboratory polysomnography or home sleep apnea testing performed within 1 year of their stroke. Linear regression models were used to evaluate study outcomes. In total, 171 participants with post-stroke OSA (117 males [68.4%] and 54 females [31.6%]) were included. Female sex was an independent predictor for greater functional impairment (β = 0.37, 95% CI 0.029-0.71, p = 0.03), increased stroke severity (β = 1.009, 95% CI 0.032-1.99, p = 0.04), and greater post-stroke depressive symptoms (β = 3.73, 95% CI 0.16-7.29, p = 0.04). Female sex was associated with lower OSA severity, as measured by the AHI (β = -5.93, 95% CI -11.21- -0.66). Sex was not an independent predictor of specific symptoms of OSA such as daytime sleepiness, snoring, tiredness, and observed apneas. Females with post-stroke OSA had poorer functional outcomes and more severe strokes compared to males, despite having lower OSA severity. Females with post-stroke OSA also exhibited more depressive symptoms. Understanding sex differences in patients with post-stroke OSA will likely facilitate better recognition of OSA and potentially improve clinical outcomes.

Screening for OSA in stroke patients: The role of a sleep educator

Obstructive Sleep Apnea (OSA) is prevalent in patients with stroke or Transient Ischemic Attack (TIA). OSA is also a risk factor for recurrent stroke and TIA. Screening for and addressing OSA in acute stroke settings is difficult because of variety of factors not the least of which is the added burden on the healthcare team. We describe the preliminary results of a pilot program instituted at our medical center and the positive impact it has on OSA screening in the acute stroke unit.

Stroke: What's Sleep Got to Do With It?

Ischemic strokes most often occur between 6 am and 12 am after awakening from sleep but up to 30% occur during sleep. Wake-up strokes (WUS) are new focal neurological deficit(s) persisting for ≥ 24 hours attributable to an ischemic event present on patient awakening. Obstructive sleep apnea (OSA) is a major risk factor for WUS because it compounds the instability of the morning environment and increases the likelihood of cardiovascular events, including hypertension, atrial fibrillation, right-to-left shunts, and stroke. Circadian-driven alterations in structural, homeostatic, and serological factors also predispose to WUS. Also, WUS patients are often not considered candidates for time-dependent intravenous thrombolysis therapy because of an uncertain onset time. However, using the tissue clock (positive diffusion weighted imaging-negative fluid-attenuated inversion recovery mismatch) dates the WUS as 3 to 4.5 hours old and permits consideration for intravenous thrombolysis and if needed mechanical thrombectomy. Given the high prevalence of moderate/severe OSA in stroke patients and its impact on stroke outcomes, screening with overnight pulse oximetry and home sleep apnea test is needed. Treating OSA poststroke remains challenging. Polysomnographic changes in sleep architecture following acute/subacute stroke may also impact upon stroke outcome.

Trazodone improves obstructive sleep apnea after ischemic stroke: a randomized, double-blind, placebo-controlled, crossover pilot study.

Low arousal threshold plays a part in the pathogenesis of obstructive sleep apnea (OSA) and may be improved by sedatives. Sedative antidepressants are frequently prescribed for stroke patients due to their high prevalence of insomnia and depression. However, the effect of sedative antidepressants on the severity of OSA in stroke patients has not been studied well. In a double-blinded randomized crossover pilot study, 22 post-acute ischemic stroke patients (mean age, 61.7 ± 10.6 y) with OSA received 100mg of trazodone or a placebo just before polysomnography, with approximately 1week between measures. The study also measured baseline heart rate variability and 24-h ambulatory blood pressure. Administration of trazodone significantly increased the percentage time of slow-wave sleep (31.5 ± 13.2 vs. 18.4 ± 8.7%; P < 0.001) and improved almost all the parameters of OSA severity, including the apnea-hypopnea index (AHI, 25.4 ± 15.4 vs. 39.1 ± 18.4 events/h; P < 0.001), the respiratory arousal index (9.8 (5.8-11.95) vs. 14.1 (11.3-18.7) events/h; P < 0.001), and the minimum oxygen saturation (80.2 ± 9.1 vs. 77.1 ± 9.6%; P = 0.016). Responders to therapy (AHI reduced by > 50%; n = 7/22) had predominant OSA during rapid-eye-movement sleep and decreased sympathetic tone, as reflected in significantly lower mean blood pressure, diastolic blood pressure, and normalized low-frequency power. Obstructive sleep apnea with comorbid ischemic stroke may be a distinctive phenotype which responds quite well to trazodone, decreasing OSA severity without increasing nocturnal hypoxia. Clinicaltrials.gov: NCT04162743, 2019/11/10.

High-flow nasal cannula ventilation therapy for obstructive sleep apnea in ischemic stroke patients requiring nasogastric tube feeding: a preliminary study

Obstructive sleep apnea (OSA) is associated with increasing risk of recurrent stroke and mortality. Nasogastric tubes used by dysphagic stroke patients may interfere with nasal continuous positive airway pressure (CPAP) due to air leakage. This study was evaluated the effects and short-term tolerability of high-flow nasal cannula (HFNC) therapy for OSA in stroke patients with nasogastric intubation. The HFNC titration study was performed in post-acute ischemic stroke patients with nasogastric intubation and OSA. Then, participants were treated with HFNC therapy in the ward for one week. Eleven participants (eight males) who were all elderly with a median age of 72 (IQR 67–82) years and a body mass index of 23.5 (IQR 22.0–26.6) completed the titration study. The HFNC therapy at a flow rate up to 50~60 L/min significantly decreased the apnea-hypopnea index from 52.0 events/h (IQR 29.9–61.9) to 26.5 events/h (IQR 3.3–34.6) and the total arousal index from 34.6 (IQR 18.6–42.3) to 15.0 (IQR 10.3–25.4). The oxygen desaturation index was also significantly decreased from 53.0 events/h (IQR 37.0–72.8) to 16.2 events/h (IQR 0.8–20.1), accompanied by a significant improvement in the minimum SpO2 level. Finally, only three participants tolerated flow rates of 50~60 L/minute in one-week treatment period. Conclusively, HFNC therapy at therapeutic flow rate is effective at reducing the OSA severity in post-acute ischemic stroke patients with nasogastric intubation. Owing to the suboptimal acceptance, HFNC might be a temporary treatment option, and CPAP therapy is suggested after the nasogastric tube is removed.

Abstract TP215: Clinical Phenotypes of Obstructive Sleep Apnea in Stroke Patients: A Cluster Analysis

Introduction: Obstructive sleep apnea (OSA) is highly prevalent in stroke survivors. Untreated OSA is associated with an increased risk of adverse cardiovascular outcomes and OSA treatment may improve neurological recovery in stroke survivors, yet OSA in stroke patients remains poorly characterized. To our knowledge, this is the first study aiming to identify OSA phenotypes in stroke survivors. Methods: Patients (n=451) with ischemic strokes and OSA (apnea-hypopnea index (AHI) ≥ 10 using a cardiopulmonary screening device (ApneaLink Plus)) were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) project. Latent class analysis was performed based on the following variables: age, sex, race/ethnicity, AHI, pre-stroke snoring, pre-stroke tiredness/fatigue, pre-stroke sleep duration, prior stroke history, initial NIHSS, BMI, hypertension, diabetes, atrial fibrillation, coronary artery disease, and congestive heart failure. Results: A model with 3 phenotype clusters provided the best fit. Cluster 1 (n=55, 12%) was defined by higher NIHSS scores and high prevalence of snoring. Patients in cluster 2 (n=253, 56%) were younger and had relatively low NIHSS scores. Cluster 3 (n=143, 32%) included patients with severe OSA and higher prevalence of medical comorbidities. Conclusion: Ischemic stroke survivors with OSA can be categorized into three clinical phenotype clusters characterized by differences in stroke severity, OSA severity, patient age and medical comorbidities. This highlights the heterogeneity of post-stroke OSA. Awareness of the different faces of OSA in patients with ischemic stroke may help clinicians identify OSA in their patients, and informs research concerning the pathophysiology and prognostication of post-stroke OSA.

Impact of obstructive sleep apnea on cardiac organ damage in patients with acute ischemic stroke.

Both obstructive sleep apnea (OSA) and cardiac organ damage have a crucial role in acute ischemic stroke. Our aim is to explore the relationship between OSA and cardiac organ damage in acute stroke patients. A total of 130 consecutive patients with acute ischemic stroke were enrolled. Patients underwent full multichannel 24-h polysomnography for evaluation of OSA and echocardiography to evaluate left ventricle (LV) mass index (LV mass/BSA, LV mass/height), thickness of interventricular septum (IVS) and posterior wall (LVPW), LV ejection fraction and left atrium enlargement. Information on occurrence of arterial hypertension and its treatment before stroke was obtained from patients' history. 61.9% (70) of patients, mostly men (67.1%), with acute stroke had OSA (AHI > 10). Patients with acute stroke and OSA showed a significant increase (P < 0.05) of LV mass index, IVS and LVPW thickness and a significant left atrial enlargement as compared with patients without OSA. LV ejection fraction was not significantly different in stroke patients with and without OSA and was within normal limits. No relationship was found among cardiac alterations, occurrence of OSA and history of hypertension. Acute stroke patients with OSA had higher LV mass and showed greater left atrial enlargement than patients without OSA. This study confirms the high prevalence of OSA in stroke patients, suggesting also an association between OSA and cardiac target organ damage. Our finding of structural LV abnormalities in acute stroke patients with OSA suggests a potential role of OSA as contributing factor in determining both cerebrovascular and cardiac damage, even in absence of clear link with a history of blood pressure elevation.

Preliminary validity and reliability of a Thai Berlin questionnaire in stroke patients.

BackgroundObstructive sleep apnea (OSA) is a major risk factor for stroke. The Berlin Questionnaire (BQ) has been shown to be a valid tool to screen for OSA. The literature has limited data on using the BQ in stroke patients; particularly in Thailand and other developing countries. Here, we aimed to develop a Thai-language Berlin Questionnaire (Thai BQ) and to preliminarily assess construct validity, test-retest reliability and the agreement of the Thai BQ with the Thai Epworth Sleepiness Scale (Thai ESS), another screening tool for OSA.MethodsA hospital-based cross-sectional study was performed from January to July, 2011. One hundred first-ever stroke patients, including acute and chronic cases, and their caregivers were enrolled. The Thai BQ was developed using the forward-backward translation method. Evaluation of construct validity was done by factor analysis. Internal consistency of the Thai BQ and the Thai ESS were evaluated using Cronbach’s alpha coefficient. Test-retest reliability and the agreement of the Thai BQ and the Thai ESS were evaluated using Cohen’s kappa coefficient.ResultsFactor analysis identified 4 main factors: Factor 1–Snoring behaviour; Factor 2–Sleepiness during driving; Factor 3–Daytime fatigue; and Factor 4–Hypertension or obesity. Cronbach’s alpha coefficient was 0.77 (95% confidence interval (CI) = 0.69-0.83) and Cohen’s kappa coefficient was 0.86 (95% CI = 0.74-0.98) in the Thai BQ. Cronbach’s alpha coefficient was 0.59 (95% CI = 0.45-0.70) and the Cohen’s kappa coefficient was 0.81 (95% CI = 0.60-1.00) in the Thai ESS. The agreement between the Thai ESS and the Thai BQ was fair.ConclusionsThe Thai BQ is a valid and reliable tool to screen for OSA in stroke patients. As factor analysis revealed 4 factors in contrast to the 3 factors in the original BQ, further modification of the Thai BQ is required.

Sleep Disorders and Stroke

Obstructive sleep apnea (OSA) is a very common condition in patients with stroke and is found in over half of stroke patients. There is a complex relationship between OSA and stroke, attributable to shared risk factors. There are numerous mechanisms by which OSA may contribute to increased stroke risk, including promotion of atherosclerosis, hypercoagulability, and adverse effects on cerebral hemodynamics. Obstructive sleep apnea is also a risk factor for hypertension, and likely for atrial fibrillation and diabetes, conditions that in turn are risk factors for stroke. OSA is also associated with poor outcomes following stroke. Further epidemiological studies are needed to assess the relationship between OSA and stroke better. Clinical trials using continuous positive airway pressure as a treatment for OSA in stroke patients are needed to determine whether treatment of this condition alters outcome following stroke.

Editorial Comment: How Much Is a Good Night’s Sleep Worth?

As Brown et al point out in this issue of Stroke , sleep disordered breathing is associated both with increased stroke risk and increased poststroke morbidity and mortality.1 Obstructive sleep apnea (OSA) is common after stroke, occurring in as many as 60 to 90% of patients, although the natural history of OSA in stroke patients, especially when OSA is first identified during the acute hospitalization, is not well studied. Because effective treatment, namely continuous positive airway pressure (CPAP), is effective at reducing sleep apnea and has been shown in small studies to be feasible in stroke patients, it is reasonable to consider planning trials to evaluate whether CPAP can improve stroke outcomes and reduce subsequent vascular events. The authors used decision–analytic modeling to identify the magnitude of benefit that identification and treatment of OSA would need to demonstrate to be considered cost-effective. They estimated the magnitude of benefit …