IMPORTANT New Apnea Study

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
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snoreking
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IMPORTANT New Apnea Study

Post by snoreking » Thu Nov 10, 2005 6:26 am

I heard a news broadcast last night that a new study about to be published in the New England Journal of Medicine reports that folks with Apnea are TWICE as likely to die from a heart attack or stroke as folks in the general population. I hate to be so grim, but obviously this study is of great interest to all of us. Let's hope that the study is referring to folks who are NOT being treated for their Apnea.
The first person who finds the study and posts a link to it gets a gold star for their star card!


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FL andy
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Post by FL andy » Thu Nov 10, 2005 7:20 am

http://www.bestsyndication.com/2005/Dan ... stroke.htm

Also available in today's Wall Street Journal, front page summary and D-1 has article.

Summary:

A Yale University study involved 1,022 patients over the age of 50 found that OSA more than doubles the chances of a stroke or death. The Yale study also found that severe cases of OSA can more than triple the risk of stroke or death.

A separate study by the University of Toronto earlier this year found severe sleep apnea were four times as likely to suffer strokes.

The Yale study showed that even with treatment sleep apnea still had an elevated risk of stroke and death.

Please read the entire article since this summary does not get all the important points.

Andy

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Post by FL andy » Thu Nov 10, 2005 7:48 am

Finally found the New England Journal report on the web:

http://content.nejm.org/cgi/content/short/353/19/2034

Another article in same issue:

http://content.nejm.org/cgi/content/short/353/19/2025.

The full study cannot be read unless one subscribes to the NEJM.

[/b]The best article is in today's Wall Street Journal print edition.

Andy

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Geocom
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Wall Street Journal Article

Post by Geocom » Thu Nov 10, 2005 8:48 am

Sleep Apnea Can Cause Strokes
Disorder More Than Doubles
Risks, Yale Researchers Say;
Tape-Recording Your Sleep

By ROBERT TOMSHO
Staff Reporter of THE WALL STREET JOURNAL
November 10, 2005; Page D1

Searching for the causes of deadly strokes, medical researchers say they have identified a culprit in the bedroom: sleep apnea.

The disorder, often undiagnosed for years, causes sleeping people to temporarily stop breathing. A number of studies have found links between sleep apnea and serious cardiovascular disease. But it wasn't clear whether sleep apnea actually led to strokes.

Now a Yale University study published in this week's New England Journal of Medicine singles out the condition as a cause of strokes. The study, which involved 1,022 patients over the age of 50, found that the most common form -- so-called obstructive sleep apnea -- more than doubles the chances of a stroke or death. The Yale study also found that severe cases of obstructive sleep apnea can more than triple the risk of stroke or death.

H. Klar Yaggi, the study's principal investigator and a sleep-medicine specialist at the Yale University School of Medicine, says the higher incidence of stroke and death remained even after researchers adjusted for other traditional stroke-risk factors such as diabetes, hypertension and obesity.

The results bolster other recent findings, including a study by University of Toronto researchers earlier this year indicating that patients with severe sleep apnea were as many as four times as likely to suffer strokes. Strokes are the third leading cause of death in the U.S. after heart disease and cancer, striking 700,000 people a year and killing 163,000 of them.

An estimated one in five American adults suffers from at least mild forms of sleep apnea, although physicians generally say treatment isn't necessary unless it involves five or more pauses in breathing per hour of sleep, along with other symptoms such as daytime drowsiness. Roughly 4% of adult American men and 2% of women suffer from the disorder to that degree, according to a study at the University of Wisconsin. But some researchers estimate that more than half of these cases go undiagnosed.

With obstructive sleep apnea, the lungs continue to work but the muscles in the throat become so relaxed that the airway becomes all or partially closed. With central sleep apnea, a far rarer form, the body temporarily stops making any effort to breathe.

Common symptoms include loud snoring, choking or gasping during sleep and daytime drowsiness, although the apnea episodes often fail to actually wake the sufferers. The disease often strikes those who have hypertension or are overweight. A 2003 study of 300 National Football League players found that 14% of them had sleep apnea, and the disease is believed to have played a role in the sudden death in 2004 of former Green Bay Packer great Reggie White.

Sleep apnea is also associated with diabetes, hypertension and driving accidents, according to the National Institutes of Health. Treatments include a mask-like device that is worn over the nose and mouth during sleep. The device is attached to a pump that pushes air through the mask to keep the upper air passage open.

One big question raised by the Yale study, however, is whether treating sleep apnea will reduce the incidence of strokes.

All 1,022 patients involved in the study had been referred to the Yale Center for Sleep Medicine for various sleep problems. Of them, 697 were diagnosed with obstructive sleep apnea and 325 had other disorders. Researchers followed up on patient outcomes for an average of about three years after the initial diagnosis.

Of the 88 incidences of strokes or death subsequently recorded, 72 occurred among the sleep-apnea patients. Many of these patients were undergoing various forms of treatment, including the pump-and-mask apparatus known as continuous positive airway pressure, or CPAP. But even with treatment, the group still had an elevated risk of stroke and death, according to the study, which was paid for by grants from the NIH, the Department of Veterans Affairs and Yale.

To some in the sleep-medicine field, that points the way to the next generation of related research. "Now what we need to know is that treating that sleep apnea decreases the stroke risk substantially," says Virend Somers, a cardiologist at the Mayo Clinic in Rochester, Minn., who wasn't involved with the Yale study. "We don't have an absolute cast-iron, randomized study to show that."

A separate study in the New England Journal of Medicine, by researchers at the University of Toronto, found that CPAP therapy didn't improve the survival rates of patients suffering from both central sleep apnea and heart failure.

Some patients do report finding relief from treatment. John Thompson, a 52-year-old former chef from New Haven, Conn., said his heavy snoring woke his wife up for years. He didn't know he had obstructive sleep apnea until a little over a year ago, when the cardiologist who was treating him for chest pains sent him to the Yale Center for Sleep Medicine for an assessment. There, doctors monitored his sleeping with cameras and electronic sensors attached to various parts of his body.

These days, Mr. Thompson, who wasn't part of the Yale study, sleeps wearing a CPAP device and says he is better-rested and has more energy. "Now I can walk further," he says. "At one point, I couldn't walk two feet."

Some researchers advise people to seek a doctor's help if their sleep partners notice that they stop breathing repeatedly during the night. For those who live alone, symptoms to watch for include difficulty concentrating, mood swings and falling asleep at inappropriate times during the day. Another strategy: Turn on a tape recorder at night and listen to how you breathe while sleeping.

"The public-health message here is that we need to continue to work on timely diagnosis and timely initiation of treatment of people with symptomatic sleep apnea," says Carl Hunt, director of the National Center on Sleep Disorders Research, part of the NIH that helped pay for the Yale study.


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Post by Guest » Thu Nov 10, 2005 10:45 am

Thanks Geocom for posting the entire article.

Your typing skills must be much better than mine. I hunt, peck and then correct typos.

Andy

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neversleeps
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Post by neversleeps » Thu Nov 10, 2005 1:05 pm

Yes, thanks Geocom!

Here is the excerpt I am most curious about:
Of the 88 incidences of strokes or death subsequently recorded, 72 occurred among the sleep-apnea patients. Many of these patients were undergoing various forms of treatment, including the pump-and-mask apparatus known as continuous positive airway pressure, or CPAP. But even with treatment, the group still had an elevated risk of stroke and death, according to the study, which was paid for by grants from the NIH, the Department of Veterans Affairs and Yale.
How many were undergoing various forms of treatment? What other forms of treatment were they using? How many within the group reported using CPAP? How many of those reportedly using CPAP were compliant? (Or were those individuals simply prescribed cpap by their physician, gave it a go, and stopped using it, as is often the case.) For those who were actually compliant, if any, how long had they been using CPAP? Were they monitoring their nightly results to see if the CPAP therapy was effective in treating their apnea? Was their "still elevated risk" equally as elevated as before they started CPAP?

So many questions....

The good news is, this prompts a study to prove that treating OSA will substantially decrease the risk of stroke.
To some in the sleep-medicine field, that points the way to the next generation of related research. "Now what we need to know is that treating that sleep apnea decreases the stroke risk substantially," says Virend Somers, a cardiologist at the Mayo Clinic in Rochester, Minn., who wasn't involved with the Yale study. "We don't have an absolute cast-iron, randomized study to show that."

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Geocom
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The Acutal Study

Post by Geocom » Thu Nov 10, 2005 2:11 pm

I have a pdf of the actual New England Journal of Medicine report, which goes into painful scientific detail.

If you'd like a copy, send me a PM with your email address, and I'll send it to you.

It's quite dense; but very informative.

George

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Morpheus
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Post by Morpheus » Thu Nov 10, 2005 2:17 pm

Sleeper, on another thread on this subject, posted this article link, which is better than the WSJ's in a number of respects:

http://www.webmd.com/content/Article/115/111500.htm

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rested gal
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Post by rested gal » Thu Nov 10, 2005 2:36 pm

Of the 88 incidences of strokes or death subsequently recorded, 72 occurred among the sleep-apnea patients. Many of these patients were undergoing various forms of treatment, including the pump-and-mask apparatus known as continuous positive airway pressure, or CPAP. But even with treatment, the group still had an elevated risk of stroke and death, according to the study, which was paid for by grants from the NIH, the Department of Veterans Affairs and Yale.
neversleeps, you had some of the exact same questions I had when I read the part quoted above! You nailed it!

If one of the "various forms of treatment" was UPPP surgery, those poor people probably still were suffering from sleep apnea. It's doubtful that they had any PSG sleep studies down the road after undergoing that particular surgery which is mostly unsuccessful as a treatment for sleep apnea.

As for the CPAP users in the study... if only 4 hours of CPAP use a night (Medicare and most insurance companies' official definition of compliance!!) was considered "treatment", then sleep apnea was still doing many hours of damage each night to the part-time cpap users. Probably there were some leaky mouths and masks involved too...with treatment air escaping out into the bedroom even during some of the "compliant" hours!

Yes, I'd like to see the details of that study. Sending you a PM, Geocom...thanks!!

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Post by kev » Thu Nov 10, 2005 2:51 pm

SCARY STUFF !!

But now that they have these facts what are they going to do about it ?

it seems to me that everyone on CPAP, should now be on oxygen too !

I don't want to wait another three years while they do another study.


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neversleeps
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Post by neversleeps » Thu Nov 10, 2005 4:23 pm

Thanks, Geocom.

An excerpt:
Many patients with the obstructive sleep apnea syndrome received some type of treatment for sleep apnea after the initial evaluation. Thirty-one percent achieved a weight reduction of 10 percent or more; 58 percent were using airway pressurization for at least four hours per night for five nights or more per week; 15 percent underwent upperairway surgery.
rested gal was right. Compliance was judged at a minimum of 4 hrs/night at a minimum of 5 days/week. That leaves plenty of untreated sleep time. Hmmm.... kind of like only taking your blood pressure medication 1/2 the time and then wondering why it's not working...

Then there's this:
The present study was not designed or powered to address adherence with treatment or the effect of treatment on outcomes. Nonetheless, our study demonstrated an increased risk of stroke or death from any cause among patients with the obstructive sleep apnea syndrome despite the administration of various therapies. Several explanations may account for this finding. First, it is likely that many of our patients had had untreated obstructive sleep apnea for years before seeking treatment, resulting in a prolonged exposure to cardiovascular risk. The median 3.4 years of follow-up may not have been a sufficient length of time to derive the potential cardiovascular therapeutic benefits. Second, reduced compliance with continuous positive airway pressure and limited efficacy of other treatments may have played a role in the failure of therapy to reduce the risk to baseline levels. Third, in contrast to thein a recent study that suggested a beneficial effect of treatment on outcomes, our population was older and had a higher prevalence of cardiovascular risk factors.
Am I reading this right???? If I'm interpreting this information correctly, they confirmed CPAP compliance (such as it is) at the beginning of the study, but not at the end of the study (a median 3.4 year followup). HELLO!!!!!! To me, that would be a crucial piece of information to have.... We all know the attrition rate for CPAP use is very high. So 58% of these people found out they had sleep apnea and started CPAP therapy at the beginning of the study. Of those verified to be compliant at the beginning of the study, how many remained so? How many stopped completely? How on earth could they fail to verify this if they were going to make the statement: Nonetheless, our study demonstrated an increased risk of stroke or death from any cause among patients with the obstructive sleep apnea syndrome despite the administration of various therapies.

I guess they figured they covered themselves by admitting they didn't address adherence with treatment. What if I hadn't read the details of this study and decided, "To hell with CPAP therapy. Obviously it doesn't do any good!" Seems like rather reckless reporting, doesn't it?

They did manage to throw in a reference to previous studies to the contrary:
Several studies have demonstrated that airway pressurization (the main medical therapy for the syndrome) can reverse hypercoagulability and hemodynamic changes and even reduce the risk of cardiovascular events.
But personally, I'd rather they'd have followed up on CPAP compliance before labeling it an ineffective treatment. Seems pretty deceptive, if you ask me.

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Post by Guest » Thu Nov 10, 2005 4:55 pm

I believe that this was reported yesterday by CBS News. Here is a link to their website. At the lower right of the screen is a list of videos of news segments aired. You might want to view the one called "A Serious Side of Snoring" listed under Health videos. It's remarkable in that it's longer than most national stories on sleep apnea.


click here for link to CBS article and video


Dan01
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Post by Dan01 » Thu Nov 10, 2005 5:04 pm

That is the article I wrote. I have a special interest because I also have OSA. Here are a couple comments:

The first study dealt with OSA not Central. I have read that some of the study participants (I can’t remember exactly where I read it) only used the CPAP 4 hours a night for 5 nights a week or so. It makes me wonder how honest they were.

The second article dealt with Central Apnea. It was not as conclusive because new advances occurred in heart failure while the study was being conducted. They kept using the term CPAP when talking about the treatment for the central apnea. I emailed the Dr. and asked if some of the participants used a bipap. Wouldn’t a bi-PAP be a better treatment for CSA?

I have not gotten a return e-mail yet and some researchers don’t return emails.

At this Sleep Apnea Special Topics page:

http://bestsyndication.com/MAINpages/sp ... _apnea.htm

Studies have indicated that CPAP therapy helps prevent heart failure. I think it is important to not sleep without the CPAP. I hook up even if I take a nap.

WebMD estimates that 1 in 5 men have OSA.


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Dan01
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Post by Dan01 » Thu Nov 10, 2005 5:06 pm

Oh yah, Rested Gal, I think the number is close to 1 in 10 women have OSA. I think my 6 year daughter has it but my two sons do not.

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neversleeps
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Post by neversleeps » Thu Nov 10, 2005 5:24 pm

Dan01,

You raise another excellent point. I assumed, because this is a scientific study, the min. 4 hrs/night, min. 5 nights/wk. was verified in the beginning of the study by accessing data from the user's machine, thus proving compliance. Given the complete lack of attention paid to the enormously important details regarding use (or non-use) of CPAP therapy over the course of the study, it would not be the least bit surprising to learn these researchers simply asked the user how long/often he/she used the machine. Nor would it be surprising to learn the user claimed to be using the machine more than they actually did.

So much for those "scientific" studies.