Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Sleep Apnea and Cardiovascular Risk: What Clinicians Need to Know

  Obstructive sleep apnea (OSA) is common in patients with hypertension, obesity, atrial fibrillation, heart failure, coronary artery disease, and stroke. Repeated upper-airway collapse produces intermittent hypoxemia, arousals, intrathoracic pressure swings, and sympathetic activation. Over time, these disturbances can place sustained stress on the cardiovascular system.

  The clinical challenge is that sleep-disordered breathing often remains undiagnosed. Loud snoring may attract attention, but many patients present with morning headaches, resistant blood pressure, nocturia, impaired concentration, or unexplained fatigue. Some patients, particularly older adults and women, may not report classic symptoms.

  Respiratory and cardiovascular clinicians can improve outcomes by recognizing high-risk patterns, selecting appropriate diagnostic testing, and integrating sleep treatment with established prevention strategies. The APSR 2022 congress provides a useful context for understanding how respiratory medicine connects with broader healthcare priorities, including multidisciplinary management.

  Why Sleep Disordered Breathing Matters

  During an obstructive event, airflow decreases or stops while respiratory effort continues. Oxygen levels may fall, carbon dioxide may rise, and the patient may briefly awaken to restore airway patency. These events can occur dozens of times per hour, fragmenting sleep even when the patient has no memory of waking.

  The resulting sympathetic surges increase heart rate and vascular tone. Repeated pressure changes inside the chest can affect ventricular loading, while inflammation, oxidative stress, and endothelial dysfunction may contribute to vascular injury. OSA can therefore act as a cardiovascular stressor alongside diabetes, smoking, dyslipidemia, and excess adiposity.

  Cardiovascular Conditions Linked To OSA

  The strongest clinical association is with hypertension, particularly when blood pressure remains elevated despite appropriate therapy. OSA may also contribute to a reduced nocturnal blood pressure dip, morning hypertension, and greater variability across the 24-hour period. Resistant hypertension should prompt a careful review of sleep symptoms and risk factors.

  Atrial fibrillation is another important concern. Intermittent hypoxemia, atrial stretch, autonomic imbalance, and structural remodeling can create a favorable environment for arrhythmia initiation and recurrence. OSA is also frequently present in heart failure and coronary disease, although the effects of treatment may differ according to whether the patient has obstructive or central sleep apnea.

  Clinicians should avoid presenting OSA as the sole cause of a cardiovascular event. The relationship is usually multifactorial, and treatment decisions should account for age, obesity, medications, alcohol use, pulmonary disease, diabetes, and baseline cardiovascular risk.

  Identifying Patients Who Need Evaluation

  Screening tools such as STOP-Bang can help identify patients who warrant further assessment. A high score is useful for risk stratification, but it does not establish the diagnosis. Physical findings may include increased neck circumference, crowded oropharyngeal anatomy, obesity, or retrognathia, yet OSA can occur without these features.

  Evaluation is especially appropriate for patients with resistant or poorly controlled hypertension, recurrent atrial fibrillation, pulmonary hypertension, heart failure, prior stroke, or significant daytime sleepiness. Bed partners may provide valuable information about witnessed apneas, gasping, or disruptive snoring.

  Polysomnography remains the reference diagnostic test because it measures sleep stages, respiratory events, oxygenation, limb movements, and cardiac signals. Home sleep apnea testing is convenient for adults with a high pretest probability of uncomplicated OSA, but it may be unsuitable when there is major cardiopulmonary disease, suspected central apnea, neuromuscular weakness, or severe insomnia.

  Interpreting Treatment And Cardiovascular Evidence

  Positive airway pressure (PAP) is the principal treatment for clinically significant OSA. Continuous PAP can reduce airway obstruction, improve oxygenation, and lower apnea-hypopnea frequency. Blood pressure reductions are often modest on average but may be more meaningful in patients with resistant hypertension, strong adherence, and substantial baseline disease.

  Evidence for preventing major cardiovascular events is complex. Randomized studies have not shown a uniform reduction in events across all patients using PAP, partly because adherence varies and some trials include minimally sleepy participants. This does not negate symptomatic benefits or the value of treating severe hypoxemia, but it reinforces the need for individualized counseling.

  Clinical situation	Useful approach	Key consideration
  Suspected uncomplicated OSA	Home sleep apnea testing or polysomnography	Confirm that pretest probability is appropriate
  Excessive daytime sleepiness with OSA	PAP therapy and adherence support	Symptom improvement is a major treatment outcome
  Resistant hypertension	Diagnose and treat OSA alongside medication review	Monitor blood pressure response rather than assuming normalization
  OSA with atrial fibrillation	PAP, weight management, and standard rhythm care	Treat OSA as part of a broader recurrence-reduction strategy
  Central sleep apnea or heart failure	Specialist assessment and targeted testing	Device selection depends on cardiac function and apnea type

  Oral appliance therapy may suit selected patients with mild to moderate OSA or those unable to tolerate PAP. Weight reduction, avoidance of alcohol near bedtime, positional therapy, and management of nasal obstruction can improve disease burden. These measures should complement, rather than replace, evidence-based cardiovascular prevention when indicated.

  Building A Practical Care Pathway

  Successful management depends on more than prescribing a device. Clinicians should review mask comfort, humidification, pressure settings, residual events, leak, and nightly usage. Early follow-up can identify barriers before poor adherence becomes established.

  Cardiovascular care should continue in parallel. Patients may need ambulatory blood pressure monitoring, lipid management, glycemic assessment, smoking cessation support, anticoagulation decisions for atrial fibrillation, and evaluation of exercise capacity. Treating sleep apnea does not remove the need for these interventions.

  Practical recommendations include:

  • Ask about snoring, witnessed apneas, nocturnal choking, sleepiness, and morning symptoms during cardiovascular assessments.
  • Use a validated screening tool, then arrange diagnostic testing rather than treating a questionnaire score as a diagnosis.
  • Prioritize PAP adherence support through early review, mask fitting, education, and troubleshooting.
  • Coordinate sleep, respiratory, primary care, and cardiology services for patients with complex disease.
  • Track blood pressure, arrhythmia burden, symptoms, and device data to assess the real-world response.

  Translating Sleep Care Into Prevention

  Clinicians should explain that the purpose of treatment may include better alertness, improved sleep quality, safer driving, blood pressure support, and reduction of physiological stress. Clear expectations can improve engagement, especially when patients do not feel dramatically different after the first few nights of therapy.

  A coordinated approach also helps distinguish persistent symptoms from untreated apnea. Residual sleepiness may reflect insufficient sleep, depression, sedating medication, anemia, thyroid disease, or another sleep disorder. Persistent nocturnal hypoxemia or central events require reassessment rather than automatic pressure escalation.

  Integrating sleep evaluation into cardiovascular practice creates an opportunity to detect a modifiable contributor to risk earlier. Review high-risk patients, arrange appropriate testing, and establish follow-up that measures both respiratory control and cardiovascular outcomes.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)