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Obstructive Sleep Apnea: A Cardiometabolic Risk Factor
Speaker: Eric Olson
Meeting: 67th Annual Scientific Sessions (2007)
Session: Comorbidities Associated with Obesity and Insulin Resistance

57.June 20th,
2008
12:17 pm I am making this post as a huge fan of Tim Russert. With all of the comments about the prevention of coronary heart disease and those particular risk factors that were present in Tim Russert, the one glaring omission that I see from lay people and MDs alike is obstructive sleep apnea. There is no mention that Mr. Russert had obstructive sleep apnea but consider that one in five adults over the age of 30 have this disorder and that it is a significant independent risk factor for coronary artery disease. (30% of people with coronary artery disease have obstructive sleep apnea.)

This sleep-related breathing disorder is obesity related (not necessarily obesity dependent) and that the risk of having this disorder increases dramatically as the neck size for men hits 17 inches. It is hard to imagine that his neck size was less than that. Obstructive sleep apnea is also an independent risk factor for hypertension which he was reported to have. I vividly remember seeing a close-up photo of him showing a very high tongue position which is also a predisposing factor for obstructive sleep apnea.

A very significant part of my dental practice is devoted to managing sleep-related breathing disorders like obstructive sleep apnea with oral appliance therapy. I am consistently stunned how many patients we find in our existing dental practice with undiagnosed obstructive sleep apnea who are seeing a cardiologist who has not asked their patient about the quality of their sleep or if they snore. I would be very curious to know if this disorder was ruled out in the years preceding Mr. Russert’s death.

I feel strongly that the world is a much better place because of Tim and I will miss his presence very much.

— Posted by David E. Lawler DDS

65.June 20th,
2008
4:07 pm
..............................................

An earlier poster suggests convincingly that sleep apnea was a possible unnamed risk factor. My husband had hypertension that required multiple medications that even then did not reduce to a desirable range. He had a battery tests including an angiogram. That result was, “Your 60 years of clean living have given you the cardiac arteries of an 18 year old.” One day I read that sleep apnea causes high blood pressure. Within two hours of going to the MD prescribed sleep study, he returned home with a CPAP. Gradually his HBP has come down and medications have been reduced.

..........

— Posted by gallega

PITTSBURGH, June 26 SCA-prevention-tactic

Tim Russert's Gift: A National Discourse on Sudden Cardiac Arrest

PITTSBURGH, June 26 /PRNewswire-USNewswire/ -- Reports indicate that NBC journalist Tim Russert died from sudden cardiac arrest (SCA) resulting from a heart attack. Russert's sudden death may help save other lives by raising awareness about the critical importance of calling 911, giving cardiopulmonary resuscitation (CPR), and using an automated external defibrillator (AED) immediately when SCA strikes.

"Perhaps Tim's final gift to the nation was to raise awareness about sudden cardiac arrest and the simple actions anyone can take to save a life," said Bobby V. Khan, MD, PhD, Board Chairman of the Sudden Cardiac Arrest Foundation and Assistant Professor of Medicine/Cardiology, Emory University School of Medicine in Atlanta.

About 500 others in the U.S. suffered SCA that fateful day. Most of them died. Their families, too, are in mourning. The 30 people who survived have come to understand they are alive and well because Good Samaritans at the scene called 911, gave CPR and used a defibrillator within minutes of their collapse.

Russert's death may not have been preventable given his extensive underlying coronary artery disease. But for tens of thousands of people who suffer SCA each year in the U.S., death does not have to be a permanent condition. The victim can be brought back to life if someone nearby has the courage, competence and confidence to act without delay.

Whether SCA is caused by a heart attack, a heart rhythm disorder, severe heart failure, an enlarged heart, sleep apnea or lightning, the lifesaving actions are the same: Call 911, give CPR and use the nearest AED. If these actions are taken within three to five minutes of collapse, the nation's survival rate of just six out of 100 victims could double or even quadruple in no time.

Perhaps the best way to honor Tim Russert and his family is to learn how to give CPR and use an AED. And to remember this: when it comes to SCA, your actions can mean the difference between staying dead and staying alive.

About the SCA Foundation:
The Sudden Cardiac Arrest Foundation, a national nonprofit organization, aims to raise awareness about sudden cardiac arrest and help save more lives. The SCA Foundation maintains a national database of survivors and experts available to speak with the media.

For more information: http://www.sca-aware.org.

SOURCE Sudden Cardiac Arrest Foundation

Thursday, June 26, 2008
Dr. Bill Blanchet: A ray of sunshine

Another heated discussion is ongoing at The Heart.org, this one about Tim Russert's untimely death: Media mulls Russert's death as cardiologists weigh in

Although I posted a couple of brief comments there, I quickly lost patience with the tone of many of the other respondents. Should you choose to read the comments, you will see that many still cling to old notions like heart attack is inevitable, defibrillators should be more widely available, "vulnerable" plaques cannot be identified before heart attacks, etc.

I quickly lose patience with this sort of outdated rhetoric. However, our good friend, Dr. Bill Blanchet of Boulder, Colorado, has a far stronger stomach for this than I do.

Here, a sample of his wonderfully persuasive comments:


Heart disease cannot be stopped but we can certainly do better!

Goals we must achieve if we hope to solve the Rube Goldberg of coronary disease:

1. Find something more reliable than Framingham risk factors to determine who is at risk. Framingham risk factors are wrong more often than they are right. If you are comfortable treating 40% of the patients destined to have heart attacks, continue to rely on “traditional” risk factors only.

2. Treat to new standards beyond NCEP/ATP-III. These accepted standards prevent at best 40% of heart attacks in patients treated. This is unacceptable, and arguably why Tim is dead today! Why prevention protocols emphasize LDL and more or less ignore HDL, triglycerides and underemphasize blood pressure eludes me.

3. Motivate patients to participate in coronary prevention. Saying “you need to get exercise and lose weight” is not adequate motivation, it hasn't worked to date and probably won't work tomorrow. If you are satisfied saying it is "the patient's fault for not listening to me" so be it, that excuse doesn't work for me!

Currently “good results” consist of being able to convince 50% of patients at risk by traditional risk factors to participate in prevention and hopefully 30% will be treated to goal. Of those treated to goal, 60% of the heart attacks will still happen anyway. Mathematically we can hope to prevent <10% of heart attacks with this approach!

I have personally found a solution to this dilemma. It goes like this:

1. EBT-CAC [electron-beam tomography coronary artery calcium] is the most reliable predictor of coronary events period, the end! Anyone who disagrees has not objectively read the literature. The only test more predictive than the initial calcium score is the follow up score 12 to 36 months later. EBT predicted Tim Russert’s event 10 years before it happened; passing his stress test gave him inappropriate reassurance 2 months before he died. If only Tim had the benefit of a second EBT sometime over the last 10 years he and his doctor would have known that what they were doing was insufficient and improvements could have been made.

2. I treat to the standard of stable calcified plaque by EBT (<15% annualized progression, preferably <1% annualized progression). This correlates with a very low incidence of coronary events. Even the ACC/AHA 2007 position paper agrees with this. This is accomplished with aspirin, omega-3 fatty acids, diet, exercise, weight control, smoking cessation, treatment of sleep apnea, stress reduction, control of HDL, triglycerides and LDL cholesterol and excellent control of BP and insulin resistance plus the recent addition of vit D-3. Meeting an LDL goal of 70 is easy but prevents only a minority of events, treating to the goal of stable CAC by EBT is a challenge but when achieved, the reward is near elimination of heart attacks and ischemic strokes. This has indeed been my personal experience!

3. A picture of plaque in the coronary artery is a monumental motivator for patients to get on board to make things better. The demonstration of progression of that plaque despite our initial therapies gets all but a few suicidal patients interested in doing a better job. I think that similar motivational results can be had with carotid imaging; the difference is that CAC by EBT is clinically validated as being a much stronger predictor of events with progression and non-events with stability than any ultrasound test including IVUS.



Wow! I couldn't have said it better.

Sadly, I doubt even Dr. Blanchet's persuasive words will do much to convince my colleagues on this forum. And the cardiologists on this forum are likely among the more inquisitive and open-minded. The ones stuck in the cath lab day and night, or implanting defibrillators, are even less inclined to entertain such conversations.

While I admire Dr. Blanchet's energy for continuing to argue with my colleagues, the lesson I take is: Take charge of health yourself. If you wait for your doctor to do it for you, you could be in the same situation as poor Tim Russert. This is an age when your physician should facilitate your success, not prevent it or leave you wallowing in ignorance.

.....While I admire Dr. Blanchet's energy for continuing to argue with my colleagues, the lesson I take is: Take charge of health yourself. If you wait for your doctor to do it for you, you could be in the same situation as poor Tim Russert. This is an age when your physician should facilitate your success, not prevent it or leave you wallowing in ignorance.

Thursday, June 26, 2008
Dr. Bill Blanchet: A ray of sunshine

........ This is accomplished with aspirin, omega-3 fatty acids, diet, exercise, weight control, smoking cessation, treatment of sleep apnea, stress reduction, control of HDL, triglycerides and LDL cholesterol and excellent control of BP and insulin resistance plus the recent addition of vit D-3. .....