6152021 Screening for Sleep Apnoea in Cardiac Rehabilitation

6/15/2021 Screening for Sleep Apnoea in Cardiac Rehabilitation Dr Frances WISE 1, 2 Mary-Anne BEER 1 Robyn SHEPPARD 1 1. CARDIAC REHABILITATION UNIT, CAULFIELD HOSPITAL, ALFRED HEALTH 2. EPWORTH MONASH REHABILITATION MEDICINE UNIT

6/15/2021 Obstructive Sleep Apnoea 2

Obstructive Sleep Apnoea 6/15/2021 A disorder in which breathing is repetitively interrupted during sleep due to collapse of the upper airway resulting in hypoxia and sleep fragmentation. Sleep 1999 3

6/15/2021 Background Obstructive Sleep Apnoea (OSA) affects 25% of men and 9% of women in Australia Snore Australia 4

6/15/2021 Background Obstructive Sleep Apnoea is associated with significant chronic diseases 5

The relationship with cardiac risk factors Prevalence of Obstructive Sleep Apnoea in Populations With Cardiovascular Disorders (CVD) Condition % Hypertension 30– 83 Ischemic heart disease 30– 58 Stroke 43– 91 HF, with reduced ejection fraction 12– 53 HF, with preserved ejection fraction 40 Hypertrophic cardiomyopathy 40 Atrial fibrillation 25– 80 End-stage renal disease 40– 60 Floras 2014 6/15/2021 6

6/15/2021 Thus, not surprisingly, OSA is recognised as a predictor of premature cardiovascular death. Floras 2014 7

WHY - did we undertake this study? “Patients with untreated sleep apnoea may experience significantly worse outcomes during their cardiac rehab and recovery” Sharma Parker 2011 OSA is underdiagnosed and undertreated in Cardiac Rehabilitation patients 6/15/2021 8

6/15/2021 9 HOW – did we perform this study? 431 cardiac rehabilitation patients completed: • the Berlin Sleep Questionnaire (BSQ), We also measured: • • • Hospital Anxiety and Depression Scale 6 Minute Walk Test (6 MWT). Body Mass Index (BMI), Body Fat % and Risk factor history

6/15/2021 HOW – did we perform this study? Berlin Sleep Questionnaire Netzer 1999 10

6/15/2021 11 HOW – did we perform this study? Score ≥ 2 on the BSQ = letter to GP to suggest Berlin Sleep Questionnaire FURTHER INVESTIGATION

6/15/2021 Next Steps? The Berlin Sleep Questionnaire is only one screening tool that is freely available for screening for OSA. 12

6/15/2021 WHAT – were the results? 38% (n = 164) of patients scored highly on BSQ & needed referral to a sleep clinic for follow up 13

WHAT – were the results? 6/15/2021 Prevalence of Risk Factors in High Scorers (164) Low Scorers (267) AGE, MEAN 63. 7 63. 6 GENDER MALE % 72. 2 77 SMOKER % 13. 4 * 9 HYPERTENSION % 68. 9 * 42 DIABETES % 28. 4 * 17. 7 NECK CM MEAN 40. 9 * 38. 5 BMI, MEAN 30. 2 * 26. 9 % BODY FAT, MEAN 31. 2 * 27. 1 WAIST CM, MEAN 104. 5 * 97 HADS ANXIETY % 35. 5 * 21. 7 HADS DEPRESSION % 32. 2 * 13. 8 EXERCISE >150 Mins/WK % 54. 2 57. 7 6 MWT MEAN ADM 478 * 501 634. 7 * 717 6 MWT MEAN DISCH 14

6/15/2021 WHAT – were the results? • Smoking is an independent risk factor for OSA • Smokers have a THREE fold increase in risk of developing OSA compared to non smokers • Prevalence of smoking in sleep apnoea patients may be as high as 35% Kashyap 2001 • “Where there’s smoke, there’s sleep apnoea!” Krishnan et al 20 15

6/15/2021 WHAT – were the results? Prevalence of Risk Factors in High Scorers (164) Low Scorers (267) AGE, MEAN 63. 7 63. 6 GENDER MALE % 72. 2 77 SMOKER % 13. 4 * 9 HYPERTENSION % 68. 9 * 42 DIABETES % 28. 4 * 17. 7 NECK CM MEAN 40. 9 * 38. 5 BMI, MEAN 30. 2 * 26. 9 % BODY FAT, MEAN 31. 2 * 27. 1 WAIST CM, MEAN 104. 5 * 97 HADS ANXIETY % 35. 5 * 21. 7 HADS DEPRESSION % 32. 2 * 13. 8 EXERCISE >150 Mins/WK % 54. 2 57. 7 6 MWT MEAN ADM 478 * 501 634. 7 * 717 6 MWT MEAN DISCH 16

6/15/2021 WHAT – were the results? • Hypertension is a key risk factor for CVD • In the medical literature a third or more of individuals with hypertension also will have OSA. Floras 2015 17

WHAT – were the results? 6/15/2021 Prevalence of Risk Factors in High Scorers (164) Low Scorers (267) AGE, MEAN 63. 7 63. 6 GENDER MALE % 72. 2 77 SMOKER % 13. 4 * 9 HYPERTENSION % 68. 9 * 42 DIABETES % 28. 4 * 17. 7 NECK CM MEAN 40. 9 * 38. 5 BMI MEAN 30. 2 * 26. 9 % BODY FAT MEAN 31. 2 * 27. 1 WAIST CM, MEAN 104. 5 * 97 HADS ANXIETY % 35. 5 * 21. 7 HADS DEPRESSION % 32. 2 * 13. 8 EXERCISE >150 Mins/WK % 54. 2 57. 7 6 MWT MEAN ADM 478 * 501 634. 7 * 717 6 MWT MEAN DISCH 18

6/15/2021 WHAT – were the results? • Intermittent hypoxia and sleep fragmentation can lead to insulin resistance Hamilton Naughton 2013 • Large published studies indicate that OSA is a predictor of diabetes, with OSA patients 30% more likely to develop diabetes. Kendzerska et al 2014 • Patients with diabetes have an increased risk of developing OSA Hamilton Naughton 2013 19

WHAT – were the results? 6/15/2021 Prevalence of Risk Factors in High Scorers (164) Low Scorers (267) AGE, MEAN 63. 7 63. 6 GENDER MALE % 72. 2 77 SMOKER % 13. 4 * 9 HYPERTENSION % 68. 9 * 42 DIABETES % 28. 4 * 17. 7 NECK CM MEAN 40. 9 * 38. 5 BMI, MEAN 30. 2 * 26. 9 % BODY FAT, MEAN 31. 2 * 27. 1 WAIST CM, MEAN 104. 5 * 97 HADS ANXIETY % 35. 5 * 21. 7 HADS DEPRESSION % 32. 2 * 13. 8 EXERCISE >150 Mins/WK % 54. 2 57. 7 6 MWT MEAN ADM 478 * 501 634. 7 * 717 6 MWT MEAN DISCH 20

6/15/2021 WHAT – were the results? • The external and internal neck circumferences and the degree of obesity are important predictors of sleep apnoea Katz 1989 • In general, the physical examination is normal in patients with OSA, aside from the presence of obesity (body mass index: >30 kg/m 2), an enlarged neck circumference (men: >43 cm [17 in]; women: >37 cm [15 in]). Downey 2018 21

6/15/2021 WHAT – were the results? Prevalence of Risk Factors in High Scorers (164) Low Scorers (267) AGE MEAN 63. 7 63. 6 GENDER MALE % 72. 2 77 SMOKER % 13. 4 * 9 HYPERTENSION % 68. 9 * 42 DIABETES % 28. 4 * 17. 7 NECK CM MEAN 40. 9 * 38. 5 BMI MEAN 30. 2 * 26. 9 % BODY FAT MEAN 31. 2 * 27. 1 WAIST CM MEAN 104. 5 * 97 HADS ANXIETY % 35. 5 * 21. 7 HADS DEPRESSION % 32. 2 * 13. 8 EXERCISE > 150 MINS/WK% 54. 2 57. 7 6 MWT ADM MEAN 478 * 501 6 MWT DISCH MEAN 634. 7 717 22

6/15/2021 WHAT – were the results? • Obesity is a major risk factor for both cardiovascular disease and OSA Wong et al 2018 • A 10% weight gain can lead to a SIX fold increase in the chances of developing OSA Peppard Young Palta 2000 23

WHAT – were the results? 6/15/2021 Prevalence of Risk Factors in High Scorers (164) Low Scorers (267) AGE, MEAN 63. 7 63. 6 GENDER MALE % 72. 2 77 SMOKER % 13. 4 * 9 HYPERTENSION % 68. 9 * 42 DIABETES % 28. 4 * 17. 7 NECK CIRCUMFERENCE CM MEAN 40. 9 * 38. 5 BMI MEAN 30. 2 * 26. 9 % BODY FAT MEAN 31. 2 * 27. 1 WAIST CM MEAN 104. 5 * 97 HADS ANXIETY % 35. 5 * 21. 7 HADS DEPRESSION % 32. 2 * 13. 8 EXERCISE > 150 MINS/WEEK % 54. 2 57. 7 6 MWT ADM 478 * 501 634. 7 * 717 6 MWT DISCH 24

6/15/2021 WHAT – were the results? • Sleep disturbance is strongly associated with depressive symptoms and health related quality of life Banack 2014 • Patients with both depression and OSA have an increased risk of death/adverse events following myocardial infarction, more than either depression or OSA alone. Hayano et al 2012 25

6/15/2021 WHAT – were the results? Prevalence of Risk Factors in High Scorers (164) Low Scorers (267) AGE MEAN 63. 7 63. 6 GENDER MALE % 72. 2 77 SMOKER % 13. 4 * 9 HYPERTENSION % 68. 9 * 42 DIABETES % 28. 4 * 17. 7 NECK CM MEAN 40. 9 * 38. 5 BMI MEAN 30. 2 * 26. 9 %BODY FAT MEAN 31. 2 * 27. 1 WAIST CM MEAN 104. 5 * 97 HADS ANXIETY % 35. 5 * 21. 7 HADS DEPRESSION % 32. 2 * 13. 8 EXERCISE > 150 MINS/WEEK % 54. 2 57. 7 6 MWT ADM 478 * 501 634. 7 * 717 6 MWT DISCH 26

6/15/2021 WHAT – were the results? • Health related quality of life influences both compliance with medical treatments and program adherence Banack 2014 • OSA is associated with impaired exercise capacity and lower peak VO 2. Beitler et al 2014 27

6/15/2021 WHAT – were the results? Prevalence of Risk Factors in High Scorers (164) Low Scorers (267) AGE MEAN 63. 7 63. 6 GENDER MALE % 72. 2 77 SMOKER % 13. 4 * 9 HYPERTENSION % 68. 9 * 42 DIABETES % 28. 4 * 17. 7 NECK CM MEAN 40. 9 * 38. 5 BMI MEAN 30. 2 * 26. 9 %BODY FAT MEAN 31. 2 * 27. 1 WAIST CM MEAN 104. 5 * 97 HADS ANXIETY % 35. 5 * 21. 7 HADS DEPRESSION % 32. 2 * 13. 8 EXERCISE > 150 MIN/WEEK % 54. 2 57. 7 6 MWT ADM 478 * 501 634. 7 * 717 6 MWT DISCH 28

6/15/2021 WHAT – were the results? To Summarise: HIGH SCORERS: • Were significantly more likely to have a history of smoking, hypertension or diabetes. • Had Higher BMI, body fat % and neck circumference higher prevalence of depression and anxiety. • Had Lower Exercise Tolerance and there was less improvement in 6 MWT by discharge. 29

6/15/2021 WHAT – were the results? Of our 164 high scorers, only 5 patients were referred by their GPs for further investigation. 30

6/15/2021 Next Steps? Our Unit is developing a protocol to initiate direct referral to sleep clinics, with examination of outcomes including Quality of Life, fat mass and mood. 31

6/15/2021 THANK YOU! 32