Obstructive Sleep Apnea versus Central Sleep Apnea
Obstructive sleep apnea is when the airwaybecomes narrowed or obstructed and you're making the effort to breathe but we do notsee any flow in air movement coming from your nose or mouth. Where central sleep apnea occurswhere your brain forgets to tell your body to breathe. If we're looking at it from avery simplistic term and so we do not see the drive to breathe. So the first step isto come into the and be seen by one of our physicians in the sleep medicine .We'll go through a questionnaire and try to determine what risk factors we think you havefor sleep apnea such as obesity, snoring, daytime sleepiness and then if we think thatyou have a high risk for meeting those criteria
then we would set you up for a sleep studyeither in your home to do an overnight sleep study or in our laboratory, depending on yoursituation. The CPAP can be used to treat both conditions and, in some patients, that isenough. However, there are some patients that have more complex types of central sleep apneathat require more complicated types of machines to treat that condition. Obstructive sleepapnea actually has been linked to a lot of other problems such as high blood pressureand then, you know, difficulty functioning during the day. If it goes untreated for along period of time there's an increased risk of early heart problems and those types ofthings.
2015 Atrial Fibrillation Patient Conference Managing AF Risk Factors Panel
Wilber: Well thank you. This is really,I think, a topic that I look forward to talking to people about and I think more and moreit's assuming increasing importance in how we take care of patients. We're going to tryto do a broad overview. We're going to focus specifically on diabetes, sleep apnea andexercise as 00:00:30 potential risk factors and how they can be modified in our care ofpatients with atrial fibrillation, but we'll try to give your broad overview of some ofthe other topics as well. So although I'm going to mostly talk about obesity today andatrial fibrillation, we'll talk about a couple of other things as well.
There are a variety of risk factors for atrialfibrillation and this was initially, I think, mostly of interest to epidemiologists, peoplewho study how disease, what the prevalence of it is, and how it comes to pass. I thinknow we've really begun to understand that central role, not only in sort of understandingthe disease but really in treating it, and if we don't consider these as we treat patientsthen I think our outcomes are not nearly as good as they might be otherwise. This is the traditional list and I think thereare probably even a few more. I've starred a few of them where I think that the evidencenow is becoming very clear that these are
potentially modifiable and that's really whatI want you to take home today. These aren't static risk factors that cause something andthen there's nothing you can do about it but treat the consequences, but in fact by intervening,both early and late, you have a chance to modify the disease and improve outcomes. What that means for you as patients is thatyou have to participate in your care and that's really something I want to emphasize; andif you're not invited to do so, then you must insist on doing it. Because I think your outcomesfor atrial fibrillation really depend on how you address each of these risk factors asthey apply to you individually.
Just to briefly talk about hypertension; wewon't spend a lot of time. It's certainly important; it's one of the most common riskfactors associated with atrial fibrillation. Somewhere between 60% and 80% of patientswho have atrial fibrillation in large populations studies have at least hypertension as a riskfactor, and by itself may account for the 20% to 25% of the overall risk of new onsetatrial fibrillation. There's some evidence that systolic bloodpressure probably plays a more important role than diastolic blood pressure, but there'sno clear threshold value. When you look in large population studies, each increment insystolic blood pressure is associated with
the increasing risk of atrial fibrillation.There's no sort of magic number necessarily that if you get below, your risk of atrialfibrillation goes away. It's probably reasonable and what I like to use as a therapeutic targetis somewhere around below 13080. What that means is that that's even below the sort oftraditional guidelines for treatment of hypertension, but it's very clear that even mild elevationsof blood pressure within the range of what we would call normal can still confer afibrisk. There's no clear superiority of one drug overanother although the control of atrial fibrillation certainly can improve the symptoms and thefrequency with which you have atrial fibrillation.
It's not clear that any single drug is absolutelybetter. There's some evidence that ACE inhibitors and ARBs, which are drugs that many of youmay be on to treat your hypertension, may be particularly beneficial, particularly whenyou have relatively advanced hypertension with end organ involvement like thickeningof the heart muscle, the left ventricular hypertrophy, as we call it. But there's also evidence that uncontrolledhypertension as you start antiarrhythmic drug treatment and after catheter ablation, ifyou enter into that with poorly controlled blood pressure, in fact, you have much pooreroutcomes than if your blood pressure is controlled.
Living with Atrial Fibrillation AFib
In a healthy heart, the rate and rhythm ofthe heartbeat are controlled by an electrical system. A series of coordinated electricalsignals start in a part of the heart called the Sinus Node. The electrical impulse thenspreads across the heart and tells it when and where to contract, or squeeze. This synchronizedheartbeat continuously circulates blood from the lungs, through the heart, and out to therest of the body to deliver oxygen. In people with atrial fibrillationalso called AFibtheelectrical signals are abnormal, and largely chaotic, and cause the heart's chambers tobeat irregularly, and often rapidly. If you have been diagnosed with AFib, you are notalone. AFib is the most common type of irregular
heartbeat, and an estimated 2.7 to 6.1 millionAmericans are living with AFib. Some people with AFib never experience symptoms and arediagnosed when a healthcare professional detects an irregular heartbeat. It's estimated thatonethird of Americans who have AFib, don't know they have it. So people at risk for AFibshould have their heart listened to, and their pulse checked regularly. Others are diagnosedbecause they experience symptoms and report them. Symptoms can include irregular, pounding,or rapid heartbeat, that some people describe as the feeling of butterflies, or a fish floppingin their chest. Dizziness, fainting, breathlessness, weakness, fatigue, and chest pain can alsooccur. These episodes of AFib can be very
frightening, and even disabling. AFib is oftenclassified, and treated, based on how often the episodes occur. Paroxsymal, or intermittentAFib, is when episodes stop spontaneously, but don't last more than 7 days. PersistentAFib is when episodes last longer than 7 days. Longstanding Persistent AFib lasts continuouslyfor more than a year. Permanent AFib is when episodes last longer than 7 days and wherea decision has been made not to stop it. There are a number of causes and risk factors forAFib including abnormalities in the heart's physical structure from things like valveproblems and previous heart attacks. Other causes and risk factors include high bloodpressure, coronary heart disease, overactive
thyroid or metabolic imbalances, lung disease,previous heart surgery, viral infections, stress, sleep apnea, and exposure to caffeine,alcohol, and certain medications. Sometimes the cause is unknown, although it is knownthat the risk of AFib increases as we age. Those with AFib have a higher risk for heartfailure and stroke, but with proper treatment, these risks can be managed. Having AFib iscertainly not a deathsentence and many AFib patients enjoy a healthy and active life.You will likely work with a cardiologist, or cardiac electrophysiologist, to treat yourAFib. One of the treatment goals is to prevent the heart from beating too fast. This ratecontrol can help reduce your symptoms. This
usually can be accomplished with medicationslike Beta Blockers and Calcium Channel Blockers. Rhythm control is a related but differenttreatment approach that allows the heart's chambers to work together to efficiently pumpblood. Your healthcare professional will let you know whether you might benefit from rhythmcontrol. If so, procedures may be necessary and include electrical cardioversion, wherea controlled shock to the chest restores the normal rhythm. Catheter ablation where radiofrequency, heat, or cryo (cold) energy is used to strategically destroy tissue and preventthe abnormal electrical impulses from spreading. Maze, or minimaze surgery is similar to catheterablation and may also use incisions to interrupt
the signals. Another critical part of treatingAFib is preventing strokes. Because the heart beats irregularly while in AFib, it affectsthe way blood flows through the heart and makes it vulnerable for forming clots. Thoseclots can travel from the heart to the brain where they can block vital blood flow andoxygen, resulting in a stroke that can be debilitating or deadly. The risk of strokein a person with AFib is 500% higher than in someone without the disease. So treatmentto reduce stroke risk is essential. Anticoagulants, also called bloodthinners, interfere withthe body's clotting mechanisms, and reduce the risk of stroke. There are now a numberof oral anticoagulants available that work