Q: I snore at night and am tired during the day. My doctor is concerned that I have sleep apnea. I have heard that sleep apnea can cause heart problems. Is this true?
A: Loud snoring may be present without sleep apnea, but it is a clue. Sleep apnea is a condition in which an individual experiences pauses in breathing multiple times during sleep, often associated with gasping for air. This prevents restful sleep and is frequently associated with daytime fatigue. If these symptoms are present the suspicion for sleep apnea is high, but a formal sleep study is needed for diagnosis. During this test, pauses in breathing associated with a drop in oxygen level (apnea episodes) are counted. Obstructive sleep apnea (OSA) is the most common type.
In addition to disrupting your sleep and that of your sleeping partner, OSA is associated with a higher risk of heart disease. Risk factors for heart disease, including high blood pressure and diabetes, are more frequent. Increased weight predisposes to sleep apnea, but poor sleep may itself induce further weight gain. Heart failure is more common. One study found that men with OSA are 58 percent more likely to develop congestive heart failure. Arrhythmias such as atrial fibrillation are more frequent and harder to treat in OSA patients.
Weight loss, exercise, smoking cessation, avoidance of alcohol and sleeping pills, and side or belly sleeping may be helpful. The most common treatment for moderate to severe sleep apnea is positive airway pressure, or PAP devices (CPAP, Auto-CPAP or BiPAP). If this fails oral appliances and, rarely, surgery are used. Treatment has been shown to reduce blood pressure and measures of heart failure and cut the recurrence rate of atrial fibrillation by greater than 40 percent. If you have abnormal sleep patterns, snoring, daytime tiredness or observed pauses in breathing during sleep, speak with your doctor about a sleep study.
Q: My husband recently had two stents put in his heart, but there was some conversation with his doctor about whether open heart surgery should be done instead. How does a doctor decide which procedure is best?
A: Coronary artery bypass surgery (CABG) and percutaneous coronary intervention (PCI) with balloons and stents are well-established treatments for coronary artery disease. Which to choose depends on a number of factors, including the extent of coronary artery disease, whether symptoms are stable or unstable, patient characteristics (such as age, diabetes or other medical conditions), status of heart muscle function, relative risks for each procedure, as well as patient preference. Remember that surgical and stent techniques are constantly being refined and improved, and the skill of those performing the procedures is important.
Both can be effective in improving blood flow to the heart and relieving symptoms, but there are trade-offs with each. CABG requires open chest surgery, with higher upfront risks and stroke rate. but offers the potential for longer-term freedom from repeat procedures. Recovery from PCI is faster but may require more future procedures. The need for longer-term combination antiplatelet therapy with drug-eluting stents may increase bleeding risk.
In individuals presenting with an acute ST elevation myocardial infarction, time to opening a blocked artery is critical and urgent PCI would be the most appropriate intervention. For control of stable angina, particularly when heart muscle function is normal and one or two arteries are blocked, PCI is a reasonable choice as long as the blockages are amenable to the procedure and blood thinners can be tolerated. Don’t forget that medications may be a suitable alternative to CABG or PCI in many circumstances.
As you can see, the decision is complex and needs to be individualized for each patient following careful discussion with your cardiology and surgical team.