What are the cardiac recommendations for Obstructive Sleep Apnea (OSA) in Coronary Artery Disease (CAD)?

From the Guidelines

For patients with coronary artery disease (CAD) and obstructive sleep apnea (OSA), the primary recommendation is to initiate continuous positive airway pressure (CPAP) therapy, as it has been shown to improve sleep measures and reduce the frequency of apneas and hypopneas, thereby decreasing cardiac stress and improving oxygenation 1.

Key Recommendations

• CPAP therapy should be used nightly, aiming for at least 4 hours of use per night, as it helps maintain open airways during sleep, reducing the frequency of apneas and hypopneas, which in turn decreases cardiac stress and improves oxygenation 1.
• Weight loss is strongly recommended for overweight or obese patients, as it can significantly improve both OSA and CAD, with a target of 5-10% body weight reduction initially advisable 1.
• Patients should also be encouraged to adopt a heart-healthy diet, such as the Mediterranean diet, and engage in regular physical activity, aiming for at least 150 minutes of moderate-intensity exercise per week.
• Smoking cessation is crucial for patients who smoke, as it benefits both cardiovascular health and sleep apnea, and alcohol consumption should be limited, particularly in the hours before bedtime, as it can worsen OSA symptoms.

Medications and Follow-up

• Regarding medications, beta-blockers (e.g., metoprolol 25-100 mg twice daily) are often prescribed for CAD patients and can be beneficial for those with OSA as well, as they may help reduce the cardiovascular effects of sleep apnea, however, caution should be exercised with sedatives and muscle relaxants, as these can exacerbate OSA symptoms.
• Regular follow-up is essential, with sleep studies recommended annually to assess OSA control and adjust CPAP settings if necessary, and cardiac evaluations, including stress tests and echocardiograms, should be performed as indicated for CAD management.

Importance of Adherence

• Patients should be educated about the importance of adherence to both CPAP therapy and CAD medications, as consistent use is crucial for optimal outcomes, and effective management of sleep apnea can lead to improved cardiovascular outcomes by reducing nocturnal hypoxemia, sympathetic activation, and blood pressure fluctuations associated with apneic events 1.

From the Research

Cardiac Recommendations for Obstructive Sleep Apnea (OSA) in Coronary Artery Disease (CAD)

The following are key points regarding cardiac recommendations for OSA in CAD:

• OSA is common in patients with CAD, and its treatment is crucial to reduce cardiovascular risk 2, 3, 4, 5, 6
• The first-line treatment for symptomatic OSA is continuous positive airway pressure (CPAP), but its value in patients without daytime sleepiness is uncertain 2
• Routine prescription of CPAP to patients with CAD and nonsleepy OSA did not significantly reduce long-term adverse cardiovascular outcomes in the intention-to-treat population 2
• However, adjusted on-treatment analysis showed a significant cardiovascular risk reduction in those who used CPAP for ≥4 hours per night or did not receive treatment 2
• It is recommended to screen for OSA in patients with resistant/poorly controlled hypertension, pulmonary hypertension, and recurrent atrial fibrillation after either cardioversion or ablation 3
• In patients with New York Heart Association class II to IV heart failure and suspicion of sleep-disordered breathing or excessive daytime sleepiness, a formal sleep assessment is reasonable 3
• CPAP should be offered to patients with severe OSA, whereas oral appliances can be considered for those with mild to moderate OSA or for CPAP-intolerant patients 3
• The use of CPAP in patients with CAD and OSA might prevent subsequent cardiovascular events, which was only demonstrated in observational studies, but not in randomized controlled trials (RCTs) 4
• The risk for major adverse cardiovascular and cerebrovascular events (MACCEs) was not increased in CAD patients with sleepy OSA on CPAP compared with patients without OSA 5

Key Considerations

• The relationship between OSA and CAD is complex, and OSA may promote the development of atherosclerosis 6
• Coronary imaging studies in subjects with OSA have shown that OSA is associated with increased cardiovascular risk 6
• The impact of CPAP therapy on CAD outcomes in OSA patients needs further investigation 4, 6
• Behavioral modifications and weight loss should be considered as part of the treatment plan for patients with OSA 3