2021 AHA Recommendations on Obstructive Sleep apnea
The American Heart Association released a new Scientific Statement on Obstructive Sleep Apnea (OSA) and Cardiovascular Disease on June 21, 2021.1 This article concisely reviews the core recommendations from the statement as they affect cardiology practice with a focus on patients who require OSA screening.
Obstructive sleep apnea and cardiovascular complications are interrelated
Apneic events during sleep lead to periods of hypercapnia with recurrent cycles of hypoxemia and reoxygenation. In addition to disrupting sleep, patients endure wide changes in intrathoracic pressure and autonomic dysregulation including increased sympathetic activation. As the article points out, these changes lead to or are associated with hypercoagulability, endothelial dysfunction, left atrial enlargement, metabolic dysregulation, and atherosclerosis. Not surprisingly, OSA has been associated with hypertension, atrial fibrillation and other arrhythmias, heart failure, coronary artery disease, stroke, pulmonary hypertension, metabolic syndrome, diabetes, and cardiovascular mortality. Indeed, the process seems to act via a feed-forward mechanism; OSA begets cardiovascular complications which begets worsening OSA.
Obstructive sleep apnea is underrecognized and undertreated in cardiovascular practice
Despite the strong connection between OSA and poor cardiovascular states and outcomes, the disease is shockingly underdiagnosed. About a third of patients had moderate or severe OSA in a racially and ethnically diverse sample of 2,230 adults, but only 1 out of 10 of these patients with clinically significant OSA had previously received a diagnosis.2 The high prevalence of OSA in middle age and older adults, low case surveillance rates, and significant cardiovascular risks of OSA are almost certainly contributing to suboptimal cardiovascular care for millions of patients nationally.
OSA screening triggered by cardiovascular disease state rather than OSA symptoms
The core signs and symptoms of OSA include excessive daytime sleepiness, morning headaches, memory impairment, decreased libido, changes in mood, nocturia, and poor concentration. To be fair, few patients present to a cardiologist with these chief complaints. So, to some extent, cardiologists can be forgiven for not immediately considering OSA as part of the larger constellation of cardiovascular risk factors. However, the AHA makes clear in their new Scientific Statement that patients with certain cardiovascular conditions should be referred for OSA screening. In some cases, this referral should be made simply based on cardiovascular diagnosis, apart from signs, symptoms, or exam findings related to OSA.
AHA screening recommendations for OSA: Practice-changing Recommendations for cardiologists
The AHA now recommends OSA screening for all patients with;
- Treatment-resistant or poorly controlled hypertension
- Pulmonary hypertension
- Recurrent atrial fibrillation status post cardioversion or ablation
This list alone likely encompasses a large number of patients in any cardiology practice, but the AHA goes on to recommend OSA screening for patients with other cardiovascular diagnoses under certain circumstances.
- A sleep study is recommended for patients with NYHA class II, III, or IV heart failure who have symptoms of sleep apnea. In these patients, the major diagnostic concern is whether the symptoms are caused by central sleep apnea or obstructive sleep apnea.
- The threshold for sleep apnea screening should be low in patients with tachy-brady syndrome, sick sinus syndrome, ventricular tachycardia, and those who have survived cardiac arrest.
- Patients with angina that tends to occur at night, a history of myocardial infarction, and those who have received appropriate cardiac stimulations (“shocks”) from implanted cardioverter-defibrillators should be sent for screening, according to the AHA.
At-home sleep apnea testing for at-risk cardiology patients
A common, lingering misconception is that OSA screening requires formal polysomnography in a sleep laboratory. Unfortunately, this misconception has real-world consequences. Patients have notoriously low adherence rates with formal polysomnography testing given the lack of providers and the onerous nature? of in-laboratory testing. Fortunately, in-home sleep apnea testing provides a convenient, accurate, and reliable alternative to formal polysomnography.
At-home sleep apnea testing has advanced considerably over the past 10 to 15 years. Indeed, this same AHA Scientific Statement mentions, “Diagnostic [sleep apnea] testing can be performed by overnight in-laboratory, multichannel polysomnography, or home sleep apnea tests.”1 Various studies indicate at-home sleep apnea testing tightly correlates with “gold standard” sleep laboratory testing for a wide variety of adult patients.3-5 Newer at-home sleep apnea testing systems, such as the WatchPAT ® HSAT from Itamar Medical, even have “self-scoring” algorithms that provide clinically reliable information on OSA diagnosis and severity.
With at-home testing, cardiologists now have the ability to directly offer at-risk patients a convenient way to screen for OSA. This should enable most cardiologists to increase the detection and treatment of OSA in their practices by an order of magnitude. This, in turn, should vastly improve cardiovascular outcomes for patients who currently suffer from occult OSA.
The award-winning WatchPAT® ONE and WatchPAT® 300 HSATs from Itamar Medical go far beyond standard HSAT metrics —including both OSA and central sleep apnea identification —to provide comprehensive sleep data that can facilitate the accurate diagnosis of sleep apnea in your cardiac patients.
1. Yeghiazarians Y, Jneid H, Tietjens JR, et al. Obstructive Sleep Apnea and Cardiovascular Disease: A Scientific Statement From the American Heart Association. Circulation. 2021;144(3):e56-e67. 10.1161/CIR.0000000000000988
2. Chen X, Wang R, Zee P, et al. Racial/Ethnic Differences in Sleep Disturbances: The Multi-Ethnic Study of Atherosclerosis (MESA). Sleep. 2015;38(6):877-888. 10.5665/sleep.4732
3. Zancanella E, do Prado LF, de Carvalho LB, Machado Junior AJ, Crespo AN, do Prado GF. Home sleep apnea testing: an accuracy study. Sleep Breath. 2021. 10.1007/s11325-021-02372-6
4. Suzuki M, Furukawa T, Sugimoto A, Kotani R, Hosogaya R. Comparison of diagnostic reliability of out-of-center sleep tests for obstructive sleep apnea between adults and children. Int J Pediatr Otorhinolaryngol. 2017;94:54-58. 10.1016/j.ijporl.2017.01.015
5. Yalamanchali S, Farajian V, Hamilton C, Pott TR, Samuelson CG, Friedman M. Diagnosis of obstructive sleep apnea by peripheral arterial tonometry: meta-analysis. JAMA Otolaryngol Head Neck Surg. 2013;139(12):1343-1350. 10.1001/jamaoto.2013.5338