CPAP effect on recurrent episodes in patients with sleep apnea and myocardial infarction☆
Introduction
Obstructive sleep apnea (OSA) is an independent risk factor for cardiovascular morbidity [1]. The prevalence of hypertension is higher in subjects with OSA in a dose-dependent manner [2]. OSA has also been associated with arrhythmias, stroke, and heart failure [3]. Similarly, the incidence of coronary artery disease (CAD) is increased with OSA [4], although the effect is more modest [5].
However, the association of OSA with acute myocardial infarction (MI) remains ambiguous. A number of cross-sectional [6], [7], [8] and case–control [9] studies have reported high rates of OSA in patients with acute coronary syndrome, whereas other studies have failed to clearly demonstrated an independent association between OSA and MI [2], [10]. Some of these studies have been criticized because they often lacked adjustment for important cardiovascular risk factors and due to the selection process of control subjects.
The effect of sleep apnea on prognosis of CAD patients is controversial. Whereas some authors [4], [11] reported an increase in mortality rates, others did not find a significant difference regarding 10-year survival in CAD patients with OSA compared with those without OSA [12]. Although an increased risk of the combined end-point of death, MI, stroke and transient ischemic attack has been described in OSA patients [7], [13], the effect of OSA on the progression of coronary injuries turns out to be less definite. Lee and coworkers [8] did not find an association between OSA and impaired microvascular perfusion after primary percutaneous coronary intervention. In contrast, Nakashima et al. [14] have reported that OSA may impair myocardial tissue perfusion in patients with MI. There is little specific information about the most relevant clinical consequences of the myocardial perfusion affectation, such as the risk of presenting recurrent MI or the need for a new revascularization procedure.
Another important issue is whether elimination of apnea–hypopneas with nasal continuous positive pressure (CPAP) reduces mortality and morbidity after acute MI. In a long-term follow-up study [15], CPAP reduces the risk of cardiovascular events, defined as cardiovascular death, acute coronary syndrome, hospitalization for heart failure, or need for coronary revascularization. However, other authors found that CPAP treatment is associated with a reduction in the number of cardiac deaths, but not in major adverse cardiac or cerebrovascular events [16]. Differences in patient selection, study design, and small study groups could explain the inconsistent results.
The objective of our study was to evaluate the association between OSA and MI and to clarify whether treatment of OSA is associated with a lower recurrence of MI. We aim to compare OSA frequency in patients with acute MI and a population-based sample of subjects without CAD. Moreover, we evaluate the impact of CPAP therapy on recurrent MI and on the need for coronary revascularization over a 6-year period.
Section snippets
Study subjects
Men and women, aged 18 or older, with acute MI admitted to the Coronary care unit (CCU) at the Hospital Universitario La Paz between 2003 and 2005 were eligible for this study. The diagnosis of MI was based on standard guidelines and was made by the attending physicians, who were blinded to this study. Acute MI, a criterion for patient inclusion, was characterized by typical rise and gradual fall (troponin) or more rapid rise and fall (CK-MB) of biochemical markers of myocardial necrosis with
Results
192 patients with acute myocardial infarction and 96 control subjects were included in the study. Table 1 shows the main characteristics of the two study groups. Both groups were homogeneous in sex, age and BMI. Out of the patients with MI, 74.5% had Killip grade I, 19.3% grade II, 5.7% grade III and 0.6% grade IV. Mean LVEF of the patients with MI was 47.5 ± 8.6%, and 43.2% presented values equal to or higher than 40%. Lastly, 52.1% of the MI patients presented level I of the NYHA
Discussion
Our study demonstrates the existence of an independent association between OSA and MI. Furthermore, it is confirmed that in CAD patients with OSA, risk of recurrent MI and revascularization was lower in OSA patients who tolerated CPAP.
Some previous studies have shown a greater prevalence of OSA in patients with MI, using higher AHI cut-points, such as 10 [4], [7] or 15 [6], [8]. However, the demonstration that an AHI ≥ 5 was associated with the development of MI is especially relevant as this is
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Grant support: Research for this study was supported by grants 01/0276 and 10/00642 from the Fondo de Investigación Sanitaria and SAF2007-62270 from the Ministerio de Educación y Ciencia and it was sponsored by Carburos Medica-Air Products.