1-MINUTE CONSULT

MAHESH B. MANNE, MD, MPH GREGORY RUTECKI, MD

Department of Internal Medicine, Cleveland Clinic Department of Internal Medicine, Cleveland Clinic

BRIEF ANSWERS
TO SPECIFIC
CLINICAL

Q: Obstructive sleep apnea: QUESTIONS

Who should be tested, and how?

A: Patients who have risk factors for ob-

structive sleep apnea (OSA) or who
report symptoms of OSA should be screened
sion5 and with a greater risk of stroke,6 cardio-
vascular disease, and death.7

for it, first with a complete sleep history and ■ CONSEQUENCES OF UNTREATED OSA
standardized questionnaire, and then by ob- Untreated OSA is associated with a number
jective testing if indicated. The gold standard of conditions7:
test for OSA is polysomnography performed • Hypertension. OSA is one of the most
overnight in a sleep laboratory. Home testing common conditions associated with re-
is an option in certain instances. sistant hypertension. Patients with severe
Common risk factors include obesity, re- OSA and resistant hypertension who com-
sistant hypertension, retrognathia, large neck ply with continuous positive airway pressure
circumference (> 17 inches in men, > 16 (CPAP) treatment have significant reduc-
inches in women), and history of stroke, atrial tions in blood pressure.
fibrillation, nocturnal arrhythmias, heart fail- • Coronary artery disease. OSA is twice as
ure, and pulmonary hypertension. Screening common in people with coronary artery
is also recommended for any patient who is disease as in those with no coronary artery Only 10% of
found on physical examination to have upper- disease. In patients with coronary artery dis-
airway narrowing or who reports symptoms people with
ease and OSA, CPAP may reduce the rate
such as loud snoring, observed episodes of ap- of nonfatal and fatal cardiovascular events. sleep apnea
nea, gasping or choking at night, unrefresh- • Heart failure. OSA is common in patients are diagnosed
ing sleep, morning headaches, unexplained with systolic dysfunction (11% to 37%).
fatigue, and excessive tiredness during the day. OSA also has been detected in more than
The American Academy of Sleep Medi- 50% of patients with heart failure with
cine suggests three opportunities to screen for preserved systolic function. CPAP treat-
OSA1: ment can improve ejection fraction in pa-
• At routine health maintenance visits tients with systolic dysfunction.
• If the patient reports clinical symptoms of • Arrythmias. Atrial fibrillation, nonsus-
OSA tained ventricular tachycardia, and com-
• If the patient has risk factors. plex ventricular ectopy have been reported
to be significantly more common in people
■ A DISMAL STATISTIC with OSA.8 If the underlying cardiac con-
The prevalence of OSA in the United States duction system is normal and there is no
is high, estimated to be 2% in women and significant thyroid dysfunction, bradyar-
4% in men in the middle-aged work force,2 rhythmias and heart block may be treated
and even more in blacks, Asians, and older effectively with CPAP.7 Treatment of OSA
adults.3 Yet only 10% of people with OSA are may decrease the incidence and severity of
diagnosed4—a dismal statistic considering the ventricular arrhythmias.7
association of OSA with resistant hyperten- • Sudden cardiac death. OSA was inde-
pendently associated with sudden cardiac
doi:10.3949/ccjm.83a.14074 death in a longitudinal study.9
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 OBSTRUCTIVE SLEEP APNEA TESTING

TABLE 1 ■ WHICH TEST TO ORDER?

If the score on the questionnaire indicates a
The STOP-Bang questionnaire moderate or high risk of OSA, the patient
for obstructive sleep apnea should undergo objective testing with poly-
Snoring. Do you snore loudly (louder than talking or loud enough to somnography or, in certain instances, home
be heard through closed doors)? testing.1 Polysomnography is the gold stan-
dard. Home testing costs less and is easier to
Tired. Do you often feel tired, fatigued, or sleepy during the daytime? arrange, but the American Academy of Sleep
Observed. Has anyone observed you stop breathing during your Medicine recommends it as an alternative to
sleep? polysomnography, in conjunction with a com-
Pressure. Do you have or are you being treated for high blood pressure? prehensive sleep evaluation, only in the fol-
lowing situations14:
Body mass index greater than 35 kg/m2? • If the patient has a high pretest probability
Age over 50? of moderate to severe OSA
• If immobility or critical illness makes poly-
Neck circumference larger than 40 cm? somnography unfeasible
Gender—male? • If direct monitoring of the response to
non-CPAP treatments for sleep apnea is
Score 1 for each yes answer. A score < 3 indicates low risk of obstruc- needed.
tive sleep apnea. A score ≥ 3 indicates moderate to high risk.
Home testing for OSA should not be used
Based on information in reference 13. in the following situations:
• If the patient has significant morbidity
such as moderate to severe pulmonary dis-
• Stroke. The Sleep Heart Health Study6 ease, neuromuscular disease, or congestive
showed that OSA is 30% more common heart failure
in patients who developed ischemic stroke. • In evaluating a patient suspected of hav-
Long-term CPAP treatment in moderate to ing comorbid sleep disorders such as cen-
Sleep apnea severe OSA and ischemic stroke is associat- tral sleep apnea, periodic limb movement
is associated ed with a reduction in the mortality rate.10 disorder, insomnia, parasomnias, circadian
• Diabetes. The Sleep Heart Health Study rhythm disorder, or narcolepsy
with glucose showed that OSA is independently associated • In screening of asymptomatic patients.
intolerance with glucose intolerance and insulin resistance Home testing has important drawbacks. It
and insulin and may lead to type 2 diabetes mellitus.11 may underestimate the severity of sleep ap-
nea. The rate of false-negative results may be
resistance ■ A QUESTIONNAIRE HELPS IDENTIFY as high as 17%. If the home test was thought
WHO NEEDS TESTING to be technically inadequate or the results
If you suspect OSA, consider administering a were inconsistent with those that were ex-
sleep disorder questionnaire such as the Ber- pected—ie, if the patient has a high pretest
lin,12 the Epworth Sleepiness Scale, or the probability of OSA based on risk factors or
STOP-Bang questionnaire (Table 1). The symptoms but negative results on home test-
STOP-Bang questionnaire is an easy-to-use ing—then the patient should undergo poly-
tool that expands on the STOP questionnaire somnography.14
(snoring, tiredness, observed apnea, high
blood pressure) with the addition of body ■ DIAGNOSIS
mass index, age, neck size, and gender. The The diagnosis of OSA is confirmed if the
Berlin questionnaire has been validated in the number of apnea events per hour (ie, the
primary care setting.12 The STOP-Bang ques- apnea-hypopnea index) on polysomnography
tionnaire has been validated in preoperative or home testing is more than 15, regardless of
settings13 but not in the primary care setting symptoms, or more than 5 in a patient who
(although it has been commonly used in pri- reports OSA symptoms. An apnea-hypopnea
mary care). index of 5 to 14 indicates mild OSA, 15 to 30
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 MANNE AND RUTECKI

indicates moderate OSA, and greater than 30 vehicle accidents by 52%, the 10-year ex-
indicates severe OSA. pected number of myocardial infarctions by
49%, and the 10-year risk of stroke by 31%.7
■ BENEFITS OF TREATMENT It has also been found to be cost-effective,
Treatment of OSA with CPAP reduces the for men and women of all ages with moder-
10-year risk of fatal and nonfatal motor ate to severe OSA.15 ■

■ REFERENCES
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National Center on Sleep Disorders Research (National Institutes of
Health). Circulation 2008; 118:1080–1111. ADDRESS: Mahesh B. Manne, MD, MPH, Department of Internal Medi-
8. Mehra R, Benjamin EJ, Shahar E, et al; Sleep Heart Health Study. cine, G10, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195;
Association of nocturnal arrhythmias with sleep-disordered breath- e-mail: [email protected]

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