Print Eric Van De Graaff, M.D.

I recently asked a patient about his compliance with therapy for obstructive sleep apnea (OSA) and got an odd response.  “What does it matter to you if I use my CPAP?”  The CPAP to which he referred is the mask that OSA sufferers wear at night to improve their oxygen levels during sleep.

On one level I can understand his question.  This is a sleeping problem, after all—not exactly the realm of cardiology.  Why should I care if he starts his day refreshed or drags himself out of bed feeling hung over?  Other patients have similarly expressed confusion (albeit less bluntly) about the relationship between OSA and heart function.  Before I clarify this connection, let me walk you through the normal physiology of sleep.

A night’s slumber is composed of many periods where the brain drifts between various levels of consciousness.  The deepest—and most restorative—stage is REM sleep, the period during which your brain is at its most active.  Since your dreams can become pretty vivid (like showing up to school for final exams that you haven’t studied for, and wearing no pants—I guess I’m revealing too much personal information) your body compensates by disconnecting your brain from your muscles.  That way when you dream about trying to fly you don’t end up smacking your spouse as you flap your wings.

The problem with this sleep-induced paralysis is that the muscles in your neck—normally in a constant state of mild contraction during breathing—relax and allow the weight of your double chin to press down on your airway and effectively choke you.  A person suffering OSA will be seen to fight violently against a closed airway while trying to get a breath in—sucking but pulling in no air, like a vacuum cleaner that accidentally engulfed the family gerbil.  This can go on for up to a minute before he succumbs to the stress of suffocation and exits REM sleep—not rousing enough to remember the episode, but with sufficient sleep disruption that he spends the next day exhausted.  This pattern can repeat itself dozens of times during the night.

Obese men are at highest risk, but I’ve seen OSA in all types.  In my opinion, if a patient or spouse suspects OSA then it’s highly likely to be present.  A sleep study will confirm the diagnosis.  The treatment is to wear a contraption known as CPAP (continuous positive airway pressure) that forces air into the lungs during inhalation so that the airway doesn’t collapse.

So how does it affect the heart?  Here’s a step-by-step lesson in OSA pathology:

  1. Nighttime breath-holding episodes lead to low oxygen levels, triggering constriction in the blood vessels that pass through the lungs.
  2. Night after night of vascular constriction leads to scarring of the small vessels.
  3. The pressure required to push blood through the lungs gradually rises, causing the right ventricle to enlarge and weaken.
  4. Without an effective right ventricle, fluid builds up in the abdomen and legs.
  5. Your doctor tries to treat swelling with diuretics (water pills), which cause the kidneys to eliminate water in the urine.  For the kidneys to get rid of fluid the blood must be effectively circulated to the kidneys, which doesn’t happen because of the weak right ventricle; the kidneys begin to fail.
  6. The patient is left with swelling that is refractory to medication; kidneys that are heading for dialysis; and, of course, feeling tired and exhausted.

Leg swelling and fatigue aren’t the only byproducts of untreated OSA.  For reasons too complicated to describe here OSA can lead to high blood pressure that is often refractory to standard doses of medications.  Furthermore, the persistent strain on the right chambers of the heart frequently leads to heart rhythm disturbances such as atrial fibrillation.

So, while I’d rather spend my office time discussing problems I can fix with catheters and pacemakers I find that I’m frequently talking about sleep habits.  Early use of CPAP can mitigate nearly all the adverse cardiac effects of OSA as well as return the patient to restorative sleep (this works even better when coupled with weight loss).  The first step to get someone to try CPAP is teaching him why he needs it.

I wish I could report that my patient listened carefully to my reasoning and vowed to renew his efforts at CPAP and lifestyle compliance.  In reality I think he blew off both me and his OSA therapy.  I’m sure I’ll see him again in the future but by then the damage might be permanent.

On an unrelated note I’d like to provide a plug for the Lifesaving Award, a new recognition at the AHA Heart Walk this May.  The purpose of this honor is to recognize people who have been placed in the challenging situation of having to perform CPR on a victim of cardiac or respiratory arrest.  The hope is that we can elevate the public’s recognition of the importance of learning basic life support skills.  If you know of someone who fits this description you can nominate her or him at this website.  The deadline is April 20th.



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9 Responses to Obstructive Sleep Apnea and Your Heart

  1. Jean says:

    My husband has severe problems with sleep. He currently takes sleeping pills prescribed by his doctor, but he still can not sleep. He will wake up within an hour of taking his pills then go back to bed til 4 or 5 am. He’ll get up and go sit down on the sofa downstairs and then falls asleep again. He can’t sleep and he can’t stay awake. Please advise…….

  2. John Wilcox says:

    Thanks for posting the article. Sleep Apnea can definitely affect so many more things than just being tired. From the heart to aggravating diabetes, it has cuts a wide path.

  3. Carol A Zrust says:

    I work at ARHC in Schuyler, Ne and quite a few of us have caught on to your blogs and really enjoy reading them, even the providers. Thanks for sharing your knowledge with all of us. (My daughter works at Bergan and sent the blog to us-now we’re hooked.)

  4. Jim says:

    After discussing the path forward after my heart attack, as well as continued treatment for atrial fibrillation, I elected (although somewhat reluctantly) to “go under the mask”. After a few apprehensive nights, I now find that I cannot sleep without it. I have never (well almost never) felt better. I would encourage all who are advised that OSA therapy maybe to their benefit to seriously consider it. I believe they will be surprised at the results of a good night’s sleep on their overall health and wellbeing.

  5. Eric Van De Graaff, M.D. says:

    Jean,

    I sympathize with the plight of your husband. While I don’t suffer from insomnia, I do have plenty of sleepless nights as a result of being on call for my cardiology practice and I know what it feels like to work the next day feeling like an extra from “The Walking Dead.”

    I’m no expert on sleep, but I have had enough experience with my own patients to know that there is no such thing as a really good sleeping pill. Medications such as Ambien tend to have a short life-span in the body and wear off half-way through the night. Others, like the over-the-counter Benadryl, stick around too long and leave you feeling hung-over the following day.

    Sleep experts recommend starting with something they call “sleep hygiene.” The following recommendations come from the National Sleep Foundation:

    – Avoid napping during the day; it can disturb the normal pattern of sleep and wakefulness.
    – Avoid stimulants such as caffeine, nicotine, and alcohol too close to bedtime. While alcohol is well known to speed the onset of sleep, it disrupts sleep in the second half as the body begins to metabolize the alcohol, causing arousal.
    – Exercise can promote good sleep. Vigorous exercise should be taken in the morning or late afternoon. A relaxing exercise, like yoga, can be done before bed to help initiate a restful night’s sleep.
    – Food can be disruptive right before sleep; stay away from large meals close to bedtime. Also dietary changes can cause sleep problems, if someone is struggling with a sleep problem, it’s not a good time to start experimenting with spicy dishes. And, remember, chocolate has caffeine.
    – Ensure adequate exposure to natural light. This is particularly important for older people who may not venture outside as frequently as children and adults. Light exposure helps maintain a healthy sleep-wake cycle.
    – Establish a regular relaxing bedtime routine. Try to avoid emotionally upsetting conversations and activities before trying to go to sleep. Don’t dwell on, or bring your problems to bed.
    – Associate your bed with sleep. It’s not a good idea to use your bed to watch TV, listen to the radio, or read.
    – Make sure that the sleep environment is pleasant and relaxing. The bed should be comfortable, the room should not be too hot or cold, or too bright.

    If you husband is already following all these rules it might be time for him to go see a sleep specialist. Good luck!

    Dr. VDG

  6. Norman says:

    I am 66 and had bad problems sleeping for years. One day around 10 years ago a friend of mine ask me to start jogging with her. I was so out of shape that I had to start of with a fast walk and work my way up. However, as I got into better shape and was able to spend around 45 minutes a day jogging I found my sleeping problems went away. I am not sure of the medical reason but it sure worked for me. Better yet, I lost a lot of weight and feel great.

  7. Glenda says:

    Dr. Graaff,
    Thank you for writing this article and I like that you added humor to it.
    I can relate to almost everything in your article. I take blood pressure medication and a diuretic. My blood pressure is under control, but I still get swelling in my ankles and the diuretic causes my potassium levels to stay on the low side. Due to the low potassium I get some awful leg, foot, toe and hip cramps. I wake up numerous times throughout the night and when it is time to get up I feel like I never even went to bed. I know I would benefit from a sleep study, but I have a phobia with having anything close to my face or neck due to an assault that occurred years ago. I know I am probably a good candidate for a heart attack or a stroke because of numerous factors. My parents have heart problems, my father has had mini strokes, I am over weight by about 30 pounds, I don’t eat right, I don’t get much exercise or sleep, now I snore and I am under a lot of stress. The good news is I don’t smoke and I drink very little.
    I recently had a visit to the ER because while I was working in my parents’ garden I started experiencing head rushes, dizziness, and shortness of breath. After about an hour of this, I became very nauseated and started experiencing pains in my chest, arm, neck, and shoulder. My pinky and ring finger on my left hand started tingling or going numb. I would say that I was over heated, but it was not hot outside, I was not sweating, the temperature was mild and I had only been in the garden for about 1 ½ hours. The good news is all the tests were normal including my stress test. It took me 11 minutes to reach 150 bpm. The ER Doctor stated he thought my symptoms were the product of my stomach acid coming up into my esophagus due to me bending over in the garden. I have a hard time believing this only because I was standing not bending. The bad news is I still don’t know what the problem was or is. I am still been experiencing chest pains, chest tightness, and sometimes a full feeling in my chest along with sharp pains on both sides of my neck. Can poor sleep cause this?

  8. Judy says:

    I had a very hard time wearing the mask. My dentist made me a sleep appliance that works great & I wear it every night.

  9. It’s interesting and a bit worrying to me that patients don’t expect healthcare providers to know and/or care about what’s going on with the rest of their body. I get that a lot, being an “oral-systemic health” dentist. We test for and treat (with oral appliances) obstructive sleep apnea in our practice, as well as do salivary diagnostics, antioxidant testing, and advanced periodontal therapy to reduce our patients’ risk of such conditions as heart attacks, strokes, diabetes, pregnancy complications, and dementia.

    Despite the fact that everything in our body is quite literally connected, I still get people (even physicians) who ask me what obstructive sleep apnea has to do with the mouth. I’ve gathered a bunch of statistics on the matter, many of which are referenced in one of my recent blog posts on sleep apnea. Check it out if you get a second.

    Daniel L. Sindelar, DMD
    President, American Academy for Oral Systemic Health

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