APNÉIA OBSTRUTIVA DO SONO e DOENÇA CARDIOVASCULAR

Apresentação em tema: "APNÉIA OBSTRUTIVA DO SONO e DOENÇA CARDIOVASCULAR"— Transcrição da apresentação:

1 APNÉIA OBSTRUTIVA DO SONO e DOENÇA CARDIOVASCULAR
Laboratório do Sono da Disciplina de Pneumologia InCor HC- FMUSP Brailia 2008 Geraldo Lorenzi-Filho

2 Trudo FJ, Am J Respir Crit Care Med, 1998

3 Hipertensão Refratária Insuficiência cardíaca
Prevalência de Distúrbios Respiratórios do Sono entre as Doenças Cardiovasculares 35% 70% Hipertensão Refratária Hipertensão 50% 30% Fibrilação Atrial 50% Insuficiência cardíaca Doença Coronariana Leung. AJRCCM 2003

4 Factors associated with OSA
Male  Age Hypertension Dislipidemia Diabetes OSA

5  Risk factors for Atherosclerosis
Male  Age Hypertension Dislipidemia Diabetes Smoking Atherosclerosis OSA

6 Phenotypic characteristics associated with hypertension in patients with obstructive sleep apnea
Drager LF et al J Hum Hypertens 2006 Jul;20(7):523-8

7 OSA »»atherosclerosis ?
Male  Age Hypertension Dislipidemia Diabetes Smoking Causal Link ? Atherosclerosis OSA

8 How can OSA affect the CV system
ronco S2 Arousal - Obstructive event SaO2 SaO2 78% 94%

9 Snore  Carotid Arteries
Vibration OBSTRUTIVE APNEA SaO2 78% 94%

10 CPAP  OSA CPAP

11 Esra Tasali et all PNAS 105 (3):1044-1049, 2008

12 Slow-wave sleep and the risk of type 2 diabetes
Esra Tasali et all PNAS 105 (3): , 2008

13 Wisconsin coort Peppard PE et al. NEJM 2000;342:

14

15 CPAP TRATAMENTO DA APNÉIA OBSTRUTIVA DO SONO
“continuous positive airway pressure” Sullivan, 1981

16 Before After Pepperell JC et al. Lancet. 2002;359:204-10.
CPAP and BP Before After Pepperell JC et al. Lancet. 2002;359:

17 OSA Cause of Hypertension
17

18 OSA »» Atherosclerosis
HYP +++ ++ OSA Atherosclerosis

19 OSA »» Atherosclerosis
HYP ++ OSA Atherosclerosis

20 Ambulatory BP monitoring x clinic
OSA is associated with absence of nocturnal BP dipping Suzuki M et all Sleep 1996, 19 (5): 32-7 24 hs BP monitoring Time (hs)

21 Ambulatory BP monitoring x clinic
OSA is associated with absence of nocturnal BP dipping Suzuki M et all Sleep 1996, 19 (5): 32-7 24 hs BP monitoring Time (hs) Masked Hypertension in OSA 35% Normotensives 130 OSA patients % Masked HYP 35% HYP Baguet JP et all J Hypertens 2008, 26 (5):

22 24 hs BP monitoring 30 min 1 min
Somers VK et al. J Clin Invest 1995;96:

23 Mean arterial pressure
11 ± 6% Mean arterial pressure  8 ± 2 % Balfors & Franklin AJRCCM150: , 1994 Acute modulation of arterial vasomotor tone Impaired endothelial relaxation? Jelic et all Sleep 25(8): 15-20, 2002 Shear stress

24 Drager LF et al. Chest 2007;131:1379-1386
OSA and LV hypertrophy * * * * LV mass index *P<0,05 Drager LF et al. Chest 2007;131:

25 Left ventricular hypertrophy
* * * * % LV hypetrophy * *P<0,05 * * P<0,0001 Drager LF et al. Chest 2007;131:

26 Arterial Stiffness PWV (m/s) 12,1 10,7 10,1 8,7
<0.001 <0.007 <0.001 <0.007 <0.001 NS PWV (m/s) 12,1 10,7 10,1 8,7 Drager LF et al. Chest 2007;131:

27 LV mass index vs PWV R=0.72; P<0.0001            
180   150           120 LV mass index                   90                      60    30 7 9 11 13 15 17 PWV (m/s) Drager LF et al. Chest 2007;131:

28 Heart Remodeling  Arterial stiffness  After Load HYP & LV remodeling
OSA LV remodeling  Arterial stiffness  After Load Drager LF et al. Chest 2007;131:

29 OSA »» Atherosclerosis
HYP +++ ++ LIP +++ + OSA Atherosclerosis

30 Intermittent Hypoxia and Atherosclerosis Animal Model
40 male mice 12 weeks Regular chow diet Intermittent hypoxia Regular chow diet Intermittent air High cholesterol diet Intermittent hypoxia High cholesterol diet Intermittent air Savranski et al. Am J Resp Crit Care Med. 2007;175:1290-7

31 IH or  Colesterol Diet » NO Aterosclerosis
Control IH  Cholesterol Diet Savranski et al. Am J Resp Crit Care Med. 2007;175:1290-7

32 IH +  Colesterol Diet » » Aterosclerosis
Control IH  Cholesterol + IH  Cholesterol Diet Savranski et al. Am J Resp Crit Care Med. 2007;175:1290-7

33 OSA »» Atherosclerosis
HYP +++ ++ + +++ LIP OSA Atherosclerosis + +++ Inflammation

34

35 SAOS e eventos cardiovasculares Seguimento de 10 anos: Eventos fatais
Controles Roncadores SAOS leve SAOS grave Incidência acumulada de eventos fatais (%) SAOS - CPAP Marin JM et al. Lancet. 2005

36 SAOS e arritimia: Fibrilação Atrial
P=0.009 P=0.46 Recorrência de FA após 12 meses P=0.013 Kanagala R et al. Circulation 2003

37 SAOS e Morte Súbita NEJM, 2005

38 Early Signs of Atherosclerosis in Patients with Obstructive Sleep Apnea
Luciano F Drager, Luiz A Bortolotto, Maria Cecília Lorenzi, Adelaide C Figueiredo, Eduardo M Krieger and Geraldo Lorenzi-Filho Sleep Laboratory, Pulmonary Division, Heart Institute (InCor), University of São Paulo Medical School, Brazil

39 Methods 15 severe OSA patients 15 mild-to-moderate OSA patients
12 age and sex-matched healthy volunteers All participants were free of hypertension, diabetes, smoking and were not on any medications. OSA patients were naive to treatment.

40 Baseline Characteristics

41 Pulse wave velocity CCA CR CF RA FA A D B  T

42 Eco-tracking ANT POST

43 PWV * p<0.0001

44 IMT † p<0.0001

45 Carotid Diameter

46 PWV P<0,001 Grupo Controle CPAP
NS P<0,001 7 8 9 10 11 12 13 7 8 9 10 11 12 13 PWV (m/s) PWV (m/s) Basal 4 months Basal 4 months Grupo Controle CPAP Drager LF et al. Am J Respir Crit Care Med. 2007

47 Espessura íntima-média da carótida
NS P=0,04 400 500 600 700 800 900 1000 1100 1200 1200 1100 1000 900 (µm) (µm) 800 700 600 500 400 Basal 4 meses Basal 4 meses Grupo Controle CPAP Drager LF et al. Am J Respir Crit Care Med. 2007

48 Cântico de Salomão, Cap 5, V 2.
“Eu dormia, mas meu coração estava acordado” LABORATÓRIO DO SONO INSTITUTO DO CORAÇÃO Cântico de Salomão, Cap 5, V 2.