Diagnosing and managing sleep apnea in patients with chronic cerebrovascular disease

a randomized trial of a home-based strategy

Dawn Bravata, Vincent McClain, Charles Austin, Jared Ferguson, Nicholas Burrus, Edward Miech, Marianne Matthias, Neale Chumbler, Susan Ofner, Brian Foresman, Jason Sico, Carlos A. Vaz Fragoso, Linda Williams, Rajiv Agarwal, John Concato, H. Klar Yaggi

Research output: Contribution to journalArticle

4 Citations (Scopus)

Abstract

Background: 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. Methods: In 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. Results: Among 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). Conclusions: Patients 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.

Original languageEnglish (US)
Pages (from-to)1-13
Number of pages13
JournalSleep and Breathing
DOIs
StateAccepted/In press - Apr 6 2017

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Cerebrovascular Disorders
Sleep Apnea Syndromes
Chronic Disease
Obstructive Sleep Apnea
Continuous Positive Airway Pressure
Polysomnography
Hypertension
Blood Pressure
Transient Ischemic Attack
Apnea
Randomized Controlled Trials
Stroke
Therapeutics

Keywords

  • Ischemic stroke
  • Sleep apnea diagnosis
  • Sleep apnea treatment
  • Transient ischemic attack

ASJC Scopus subject areas

  • Otorhinolaryngology
  • Clinical Neurology

Cite this

Diagnosing and managing sleep apnea in patients with chronic cerebrovascular disease : a randomized trial of a home-based strategy. / Bravata, Dawn; McClain, Vincent; Austin, Charles; Ferguson, Jared; Burrus, Nicholas; Miech, Edward; Matthias, Marianne; Chumbler, Neale; Ofner, Susan; Foresman, Brian; Sico, Jason; Vaz Fragoso, Carlos A.; Williams, Linda; Agarwal, Rajiv; Concato, John; Klar Yaggi, H.

In: Sleep and Breathing, 06.04.2017, p. 1-13.

Research output: Contribution to journalArticle

Bravata, Dawn ; McClain, Vincent ; Austin, Charles ; Ferguson, Jared ; Burrus, Nicholas ; Miech, Edward ; Matthias, Marianne ; Chumbler, Neale ; Ofner, Susan ; Foresman, Brian ; Sico, Jason ; Vaz Fragoso, Carlos A. ; Williams, Linda ; Agarwal, Rajiv ; Concato, John ; Klar Yaggi, H. / Diagnosing and managing sleep apnea in patients with chronic cerebrovascular disease : a randomized trial of a home-based strategy. In: Sleep and Breathing. 2017 ; pp. 1-13.
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abstract = "Background: 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. Methods: In 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. Results: Among 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). Conclusions: Patients 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.",
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T2 - a randomized trial of a home-based strategy

AU - Bravata, Dawn

AU - McClain, Vincent

AU - Austin, Charles

AU - Ferguson, Jared

AU - Burrus, Nicholas

AU - Miech, Edward

AU - Matthias, Marianne

AU - Chumbler, Neale

AU - Ofner, Susan

AU - Foresman, Brian

AU - Sico, Jason

AU - Vaz Fragoso, Carlos A.

AU - Williams, Linda

AU - Agarwal, Rajiv

AU - Concato, John

AU - Klar Yaggi, H.

PY - 2017/4/6

Y1 - 2017/4/6

N2 - Background: 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. Methods: In 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. Results: Among 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). Conclusions: Patients 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.

AB - Background: 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. Methods: In 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. Results: Among 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). Conclusions: Patients 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.

KW - Ischemic stroke

KW - Sleep apnea diagnosis

KW - Sleep apnea treatment

KW - Transient ischemic attack

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