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Conseqüências Cardiovasculares da AOS
Geraldo Lorenzi-Filho
Professor Livre Docente
Lab do Sono, Disciplina de Pneumologia
InCor, FM USP
[email protected]
Conflito de interess
• Laboratório do sono do InCor– Grants e colaboração
– Philips-Respironics
– Resmed
– Fisher-Paykel
– Equipamentos
– FAPESP, Fundação Zerbini, CnPq, Finep
Prevalência de Distúrbios Respiratórios do Sono entre as Doenças Cardiovasculares
Hipertensão
35%
Hipertensão Refratária
70%
Doença Coronariana
Fibrilação Atrial
Insuficiência cardíaca
50%
50%
30%
Leung. AJRCCM 2003
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SaO2
94%78%
SNORE
OBSTRUTIVE
APNEA
Polissonografia
De que forma a AOS pode afetar o SCV?
SaO2
94%
SNORE
OBSTRUTIVE
APNEA
�SaO2�SaO2
⇑CO2⇑CO2
De que forma a AOS pode afetar o SCV?
SaO2
94%78%
AROUSAL
SNORE
OBSTRUTIVE
APNEA
�SaO2�SaO2
⇑CO2⇑CO2
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De que forma a AOS pode afetar o SCV?
SaO2
94%78%
AROUSAL
SNORE
OBSTRUTIVE
APNEA
�SaO2�SaO2
----
-
-
⇑CO2⇑CO2
CPAP--------------------------
CPAP � OSA
APNEIA OBSTRUTIVA DO SONO
�Conceitos
• Hipertensão Arterial Sistêmica
• Arritimia Cardíaca
• Mortalidade
• Aterosclerose
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CPAP and BP
Before After
Pepperell JC et al. Lancet. 2002;359:204 -10.
OSA
Cause of Hypertension
11
APNEIA OBSTRUTIVA DO SONO
�Conceitos
�Hipertensão Arterial Sistêmica
• Arritimia Cardíaca
• Mortalidade
• Aterosclerose
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SAOS e arritimia: Fibrilação Atrial
Kanagala R et al. Circulation 2003
Rec
orrê
ncia
de
FA
apó
s 12
m
eses
0102030405060708090
100
Controles SAOS tratado SAOS nãotratado
P=0.46
P=0.009
P=0.013
APNEIA OBSTRUTIVA DO SONO
�Conceitos
�Hipertensão Arterial Sistêmica
�Arritimia Cardíaca
• Mortalidade
• Aterosclerose
SAOS e Morte Súbita
Gami et al N Engl J Med. 2005;352(12):1206-14.
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OSA and fatal cardiovascular eventsFollow up 10 years
Marin JM et al Lancet 365: 1046-1053, 2005
264
377
403
235
372
1,651
OSA and fatal cardiovascular events
Marin JM et al Lancet 365: 1046-1053, 2005
Number HR (IC) Cohort Publication
1,651Heathy subjectsSevere OSA(n= 235)
2.87(1.17 – 7.51)
Spain Follow up
10 y
J Marin Lancet2005
OSA and fatal cardiovascular events
Number HR (IC) Cohort Publication
1,651Heathy subjectsSevere OSA(n= 235)
2.87(1.17 – 7.51)
Spain J Marin Lancet2005
Wisconsin Cohort: Population Based Study 1,522 subjec ts
Young T et al, SLEEP 31(8): 1071-1078, 2008
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OSA and fatal cardiovascular events
Number HR (IC) Cohort Publication
1,651Heathy subjectsSevere OSA(n= 235)
2.87(1.17 – 7.51)
Spain J Marin Lancet2005
1,522No OSASevere OSA(n = 63)
3.8 (1.6 – 9.0)
Wisconsin
Follow up18 y
Young TSLEEP2008
OSA and fatal cardiovascular events
Number HR (IC) Cohort Publication
1,651Heathy subjectsSevere OSA(n= 235)
2.87(1.17 – 7.51)
Spain J Marin Lancet2005
1,522No OSASevere OSA(n = 63)
3.8 (1.6 – 9.0)
Wisconsin
Young TSLEEP2008
Sleep Heart Health Study 6,441 subjects from differen t cohorts across USA
Punjab N et al PLOS: 6 (8) e 100132, 2009
OSA and fatal cardiovascular events
Number HR (IC) Cohort Publication
1,651Heathy subjectsSevere OSA(n= 235)
2.87(1.17 – 7.51)
SpainFollow up
10 y
J Marin Lancet2005
1,522No OSASevere OSA(n = 63)
3.8 (1.6 – 9.0)
WisconsinFollow up
18 y
Young TSLEEP2008
6,441No OSASevere OSA(n= 341)
1. 5 (1.1 – 1.9)
SHHSFollow up
8.2 y
PunjabPLOS2009
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APNEIA OBSTRUTIVA DO SONO
�Conceitos
�Hipertensão Arterial Sistêmica
�Arritimia Cardíaca
�Mortalidade – Estudo SAVE
• Aterosclerose
Arterial Stiffness Pulse wave velocity (PWV)
A D B
A
B
∆∆∆∆ T
CCA
CRCF
RA
FA
Echo-tracking
Intima media thickness (IMT) Carotid diameter
ANT POST
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OSA »»atherosclerosis ?
OSA HTN
• Male• ↑↑↑↑ Age• Hypertension• Dislipidemia• Diabetes
No co-morbidities
~ 50% of OSA - HTN~30% of HTN - OSA
Arterial Stiffness
88,5
99,510
10,511
11,512
12,513
Control OSA HTN OSA + HTN
PW
V (
m/
s)
8,7
10,710,1
12,1
<0.001
<0.001
<0.007
NS<0.001
<0.007
Drager LF et al. Chest 2007;131:1379-1386n = 15 15 15 15
OSA and LV hypertrophy
Drager LF et al. Chest 2007;131:1379-1386
60
70
80
90
100
110
120
130
Control OSA HTN OSA+HTN
*
LV m
ass
inde
x
**
* *P<0,05
n = 15 15 15 15
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400
500
600
700
800
900
1000
1100
1200
1300
1400
Controls HTNOSA OSA+HTN
P<0.05
P<0.05
P<0.05
P<0.001
Carotid Intima Media Thickness (µµµµm)
Drager LF et al. Hypertension 53: 64-69 2009n 22 25 20 27
Carotid Diameter (µµµµm)
550057506000625065006750700072507500775080008250850087509000925095009750
100001025010500
Controls HTNOSA OSA+HTN
P<0.05
P<0.05
P<0.05
P<0.001
Drager LF et al. Hypertension 53: 64-69, 2009
n 22 25 20 27
Carotid Distensibility (Kpa -1 10-3)
0
5
10
15
20
25
30
35
Controls HTNOSA OSA+HTN
P<0.05
P<0.05
P<0.001
Drager LF et al. Hypertension 53: 64-69, 2009n 22 25 20 27
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The impact of continuous positive
airway pressure (CPAP) on
validated markers of
atherosclerosis.
Drager LF et al. Am J Respir Crit Care Med. 2007;176:706-12.
Methods
No treatment (NT)
(N=12)
24-h blood pressure monitoringSerum catecholamine
C-reactive protein
VASCULAR PARAMETERS
24 OSA patients AHI>30
CPAP
(N=12)
4 months
Randomization
Baseline
Pulse Wave Velocity
Arterial Stiffness
Baseline 4 months
OSA-NT OSA-CPAP
NS
7
8
9
10
11
12
13
PW
V (
m/
s)
Baseline 4 months
P=0.002
PW
V (
m/
s)
7
8
9
10
11
12
13
P<0.001
Drager LF et al. Am J Respir Crit Care Med. 2007;176:706-12.
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Intima-media thickness
Baseline 4 months
OSA-NT OSA-CPAP
NS
Baseline 4 months
P=0.04
P=0.02
IM
T (
µm
)
400
500
600
700
800
900
1000
1100
1200
400
500
IM
T (
µm
)
600
700
800
900
1000
1100
1200
Drager LF et al. Am J Respir Crit Care Med. 2007;176:706-12.
Carotid Diameter
Baseline 4 months
OSA-NT OSA-CPAP
NS
Baseline 4 months
NS
NS
5500
Ca
ro
tid
dia
mete
r (
µm
)
6000
6500
7000
7500
8000
8500
9000
9500
5500
Ca
ro
tid
dia
mete
r (
µm
)
6000
6500
7000
7500
8000
8500
9000
9500
Drager LF et al. Am J Respir Crit Care Med. 2007;176:706-12.
Conclusão
• AOS é pouco diagnosticada, e quando não tratada faz muito mal .....
• OBRIGADO!• [email protected]
