CLINICAL REVIEWObstructive sleep apnea and coronary artery disease
Introduction
Coronary artery disease (CAD) is a chronic, life-threatening disease. Progressive arteriosclerosis in the coronary arteries may lead to intimal thickening and eventual stenosis of the coronary arteries, with flow limitation and a subsequent imbalance of myocardial oxygen supply and demand, causing stable angina pectoris or its equivalents. Atherosclerotic plaque rupture with associated platelet adhesion and thrombus formation form the basis of acute coronary syndromes ranging from unstable angina to non-Q-wave and Q-wave myocardial infarction.1
Although mortality due to CAD has slightly decreased in the past decade, CAD remains the most common cause of death, with an incidence of 380 myocardial infarctions per 100 000 persons aged between 36 and 64 years per year.2 In the Physicians’ Health Study, the incidence was even higher, with 440 myocardial infarctions per 100 000 physicians per year.3 Risk factors, lifestyle and socio-economic circumstances probably account for the large regional variation.2
Obstructive sleep apnea (OSA) is characterized by repetitive collapse of the upper airway, thereby inducing apnea and hypopnea episodes despite persistent thoracic and abdominal respiratory effort. The disease has a high prevalence in the general population. It is estimated that in the middle-aged population about 4% of men and 2% of women suffer from manifest OSA.4 Numerous deleterious effects result from obstructive apnea and hypopnea with large negative intrathoracic pressure changes and blood gas deterioration. It has long been known that OSA causes substantial sleep fragmentation with excessive daytime sleepiness.5 Moreover, intensive research in recent years has also revealed negative consequences for the cardiovascular system, such as pulmonary hypertension, congestive heart failure, stroke, atrial fibrillation, and left ventricular diastolic dysfunction.6, 7, 8, 9, 10 This review focuses on the association of OSA and coronary artery disease (CAD), including ischemia, ventricular arrhythmias and arterial hypertension, and its prognostic implications.
Section snippets
Pathophysiology
The pathophysiological interaction between OSA and coronary artery disease is complex and comprises neural, humoral, mechanical and hemodynamic components (Figure 1).
Myocardial ischemia
As mentioned above, myocardial ischemia occurs as a result of reduced oxygen supply or increased oxygen demand. OSA may reduce myocardial blood flow and/or increase demand by acute changes in heart rate on the one hand and increase in afterload on the other hand. This occurs in the setting of reduced oxygen supply caused by apnea-associated hypoxemia. These factors may predispose to myocardial ischemia. Indeed, asymptomatic ST-segment depressions during sleep were evident in patients with OSA
Effect of CPAP treatment
General therapeutic options for OSA comprise first of all reduction of body weight, which may reduce the severity of OSA,132 but also abstinence from alcohol and sedatives, positional therapy or treatment of nasal obstruction. More specific therapeutic options for OSA involve oral appliances or in selected patients surgical approaches.133, 134 Recently, atrial overdrive pacing has been suggested as new alternative therapy for OSA, however subsequent studies could not confirm the beneficial
References (172)
- et al.
Leftward shift of the interventricular septum and pulsus paradoxus in obstructive sleep apnea syndrome
Chest
(1991) - et al.
Hemodynamic effects of simulated obstructive apneas in humans with and without heart failure
Chest
(2001) Right and left ventricular functional impairment and sleep apnea
Clin Chest Med
(1992)- et al.
Augmented resting sympathetic activity in awake patients with obstructive sleep apnea
Chest
(1993) - et al.
Neural and humoral mechanisms mediating cardiovascular responses to obstructive sleep apnea
Respir Physiol
(2000) - et al.
Autonomic tone as a cardiovascular risk factor: the dangers of chronic fight or flight
Mayo Clin Proc
(2002) - et al.
Neurohumoral activation as a link to systemic manifestations of chronic lung disease
Chest
(2005) - et al.
Cardiac cachexia: a syndrome with impaired survival and immune and neuroendocrine activation
Chest
(1999) The neurohormonal hypothesis: a theory to explain the mechanism of disease progression in heart failure
J Am Coll Cardiol
(1992)- et al.
Sleep apnea and glucose metabolism: the new challenge
Sleep Med
(2006)
Obesity and cardiovascular disease: the hippocrates paradox?
J Am Coll Cardiol
Effects of nasal continuous positive airway pressure on soluble cell adhesion molecules in patients with obstructive sleep apnea syndrome
Am J Med
Creatine phosphokinase elevation in obstructive sleep apnea syndrome: an unknown association?
Chest
Hematocrit levels in sleep apnea
Chest
ST-segment depression during sleep in obstructive sleep apnea
Am J Cardiol
Sleep apnoea and nocturnal angina
Lancet
Sleep-related myocardial ischemia and sleep structure in patients with obstructive sleep apnea and coronary heart disease
Chest
Sleep-disordered breathing and myocardial ischemia in patients with coronary artery disease
Chest
Relationship of ventricular ectopy to oxyhemoglobin desaturation in patients with obstructive sleep apnea
Chest
Cardiac arrhythmia and conduction disturbances during sleep in 400 patients with sleep apnea syndrome
Am J Cardiol
Sleep-related breathing disorders are associated with ventricular arrhythmias in patients with an implantable cardioverter-defibrillator
Chest
Cardiac rhythm disturbances in the obstructive sleep apnea syndrome: effects of nasal continuous positive airway pressure therapy
Chest
Leitlinie Koronare Herzkrankheit/Angina pectoris
Z Kardiol
Regionale Unterschiede der Herz-Kreislauf-Mortalität
Deut Ärzteblatt
Steering Committee of the Physicians’ Health Study Research Group
N Engl J Med
The occurrence of sleep-disordered breathing among middle-aged adults
N Engl J Med
Sleep apnea—a major public health problem
N Engl J Med
Obstructive sleep apnea syndrome affects left ventricular diastolic function: effects of nasal continuous positive airway pressure in men
Circulation
Sleep apnea and heart failure: Part I: obstructive sleep apnea
Circulation
Obstructive sleep apnea as a risk factor for stroke and death
N Engl J Med
Association of atrial fibrillation and obstructive sleep apnea
Circulation
Pulmonary hypertension and sleep-related breathing disorders
Pneumologie
Obstructive sleep apnea: implications for cardiac and vascular disease
JAMA
Leftward septal displacement during right ventricular loading in man
Circulation
Effect of negative intrathoracic pressure on left ventricular pressure dynamics and relaxation
J Appl Physiol
Acute and chronic effects of airway obstruction on canine left ventricular performance
Am J Respir Crit Care Med
Reduced stroke volume related to pleural pressure in obstructive sleep apnea
J Appl Physiol
Sympathetic nerve activity in obstructive sleep apnoea
Acta Physiol Scand
Contrasting effects of hypoxia and hypercapnia on ventilation and sympathetic activity in humans
J Appl Physiol
Neurocirculatory consequences of negative intrathoracic pressure vs. asphyxia during voluntary apnea
J Appl Physiol
Contribution of tonic chemoreflex activation to sympathetic activity and blood pressure in patients with obstructive sleep apnea
Circulation
Selective potentiation of peripheral chemoreflex sensitivity in obstructive sleep apnea
Circulation
Immediate effects of arousal from sleep on cardiac autonomic outflow in the absence of breathing in dogs
J Appl Physiol
Sympathetic-nerve activity during sleep in normal subjects
N Engl J Med
Altered cardiovascular variability in obstructive sleep apnea
Circulation
Sympathetic neural mechanisms in obstructive sleep apnea
J Clin Invest
Sympathetic activity in obese subjects with and without obstructive sleep apnea
Circulation
Sympathetic over activity in the etiology of hypertension of obstructive sleep apnea
Sleep
Obstructive sleep apnea
Ann Intern Med
Autonomic imbalance, hypertension, and cardiovascular risk
Am J Hypertens
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The most important references are denoted by an asterisk.