Sleep Apnea and Cardiovascular Disease - SCHOLARLY ARTICLES: Sleep

Circulation. 2008;118:1080-1111.
© 2008 American Heart Association, Inc.

AHA/ACCF Scientific Statement
Sleep Apnea and Cardiovascular Disease

An American Heart Association/American College of Cardiology Foundation Scientific Statement From the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council on Cardiovascular Nursing In Collaboration With the National Heart, Lung, and Blood Institute National Center on Sleep Disorders Research (National Institutes of Health)

Virend K. Somers, MD, DPhil, FAHA, FACC, Chair; David P. White, MD, Co-Chair; Raouf Amin, MD, Co-Chair; William T. Abraham, MD, FAHA, FACC; Fernando Costa, MD, FAHA; Antonio Culebras, MD, FAHA; Stephen Daniels, MD, PhD, FAHA; John S. Floras, MD, DPhil, FAHA, FACC; Carl E. Hunt, MD; Lyle J. Olson, MD, FACC; Thomas G. Pickering, MD, DPhil, FAHA; Richard Russell, MD, FAHA, FACC; Mary Woo, RN, PhD, FAHA; Terry Young, PhD

Key Words: AHA Scientific Statements • sleep • apnea • arrhythmia • blood pressure • cerebrovascular disorders • death, sudden

Introduction
Sleep-related breathing disorders are highly prevalent in patients with established cardiovascular disease. Obstructive sleep apnea (OSA) affects an estimated 15 million adult Americans and is present in a large proportion of patients with hypertension and in those with other cardiovascular disorders, including coronary artery disease, stroke, and atrial fibrillation.1–14 In contrast, central sleep apnea (CSA) occurs mainly in patients with heart failure.15–19 The purpose of this Scientific Statement is to describe the types and prevalence of sleep apnea and its relevance to individuals who either are at risk for or already have established cardiovascular disease. Special emphasis is given to recognizing the patient with cardiovascular disease who has coexisting sleep apnea, to understanding the mechanisms by which sleep apnea may contribute to the progression of the cardiovascular condition, and to identifying strategies for treatment. This document is not intended as a systematic review but rather seeks to highlight concepts and evidence important to understanding the interactions between sleep apnea and cardiovascular disease, with particular attention to more recent advances in patient-oriented research. Implicit in this first American Heart Association/American College of Cardiology Scientific Statement on Sleep Apnea and Cardiovascular Disease is the recognition that, although holding great promise, this general area is in need of a substantially expanded knowledge base. Specific questions include whether sleep apnea is important in initiating the development of cardiac and vascular disease, whether sleep apnea in patients with established cardiovascular disease accelerates disease progression, and whether treatment of sleep apnea results in clinical improvement, fewer cardiovascular events, and reduced mortality.

Experimental approaches directed at addressing these issues are limited by several considerations. First, the close association between obesity and OSA often obscures differentiation between the effects of obesity, the effects of OSA, and the effects of synergies between these conditions. Second, multiple comorbidities, including cardiovascular disease, metabolic syndrome, and diabetes, often are present in patients with sleep apnea. Hence, it becomes unclear whether abnormalities evident in the sleep apnea patient with cardiovascular disease are secondary to the sleep apnea, the cardiovascular condition, or both. The third consideration relates to randomization of sleep apnea patients to active or no treatment. Although this is a reasonable strategy for identifying the mechanistic and prognostic consequences of sleep apnea per se, it is limited by the difficulties inherent in any placebo-controlled treatment study of sleep apnea and the need to consider treatment in patients with severe daytime somnolence, even in the absence of associated cardiovascular disease.