Screen cardiovascular disease patients for sleep apnea, AHA recommends

Obstructive sleep apnea (OSA) is often underrecognized and undertreated in cardiovascular practice despite its high prevalence in patients with heart disease, according to a scientific statement by the American Heart Association (AHA).

OSA creates vulnerability among cardiac patients to adverse cardiovascular outcomes, the statement said. Its prevalence is as high as 40% to 80% in patients with hypertension, heart failure, coronary artery disease, pulmonary hypertension, atrial fibrillation, or stroke. The AHA Scientific Statement was published by Circulation online on June 21.

It recommended:

• Screen for OSA in patients with resistant/poorly controlled hypertension, pulmonary hypertension, and recurrent atrial fibrillation after either cardioversion or ablation.
• A formal sleep assessment is reasonable for patients with New York Heart Association class II to IV heart failure and suspicion of sleep-disordered breathing or excessive daytime sleepiness.
• Evaluation for sleep apnea should be considered in patients with tachy-brady syndrome or ventricular tachycardia or survivors of sudden cardiac death in whom sleep apnea is suspected after a comprehensive sleep assessment.
• After stroke, clinical equipoise exists with respect to OSA screening and treatment.
• Patients with nocturnally occurring angina, myocardial infarction, arrhythmias, or appropriate shocks from implanted cardioverter-defibrillators may be especially likely to have comorbid sleep apnea.
• All patients with OSA should be considered for treatment, including behavioral modifications and weight loss.
• Continuous positive airway pressure (CPAP) should be offered to patients with severe OSA. Oral appliances can be considered for those with mild to moderate OSA or for patients who cannot tolerate CPAP. Follow-up sleep testing should be performed to assess the effectiveness of treatment.

OSA is widely underdiagnosed; 86% to 95% of individuals with clinically significant OSA in population surveys report no prior diagnosis, and underdiagnosis is particularly prevalent in Black patients, according to the scientific statement.

“The high prevalence and comorbidity of OSA in patients with CVD [cardiovascular disease], coupled with evidence of improved patient-centered outcomes, mood, and work productivity with OSA treatment in patients with CVD, provide a rationale for OSA screening,” the scientific statement read.

Screening approaches include targeted elicitation of symptoms of OSA through medical history, screening questionnaires, or sleep apnea screening devices, according to the statement. It noted that a sleep history, ideally obtained with assistance from a bed partner, should ask about frequency and severity of snoring, gasping or snorting during sleep, frequent awakening or sleep disruption, and excessive daytime sleepiness, particularly difficulty maintaining alertness, involuntary periods of dozing, or drowsy driving.

Commonly used screening questionnaires include the Berlin Questionnaire, the STOP-BANG (Snoring, Tiredness, Observed Apnea, Blood Pressure, Body Mass Index, Age, Neck Circumference, and Gender), and the STOP, which include symptoms of snoring, sleepiness, and other features associated with increased OSA risk, according to the statement. These questionnaires have reported sensitivity between 77% and 89% but lower specificity of 32% to 34%. The Epworth Sleepiness Scale focuses on propensity for dozing, has 67% specificity but 42% sensitivity, and is a poor screening tool, the statement said.

Screening instruments may underperform in certain groups, including women, who more commonly report fatigue and insomnia symptoms than sleepiness, and in patients with underlying cardiovascular disease, heart failure, atrial fibrillation, or history of stroke, according to the statement.