Original ArticleSleep-disordered breathing among acute ischemic stroke patients in Brazil
Introduction
Sleep-disordered breathing (SDB) and cerebrovascular disease (CVD) are highly prevalent worldwide [1], [2]. Recent accumulating clinical and epidemiological evidences suggest a strong causal relationship between them [3], [4], [5], [6], [7], [8]. Obstructive sleep apnea (OSA) is the most common form of SDB and it is characterized by repetitive episodes of partial or complete upper airway obstruction during sleep [9]. A population-based survey study in Brazil identified that around 32% of adults fulfill the criteria for OSA syndrome, according to the International Classification of Sleep Disorders – ICSD-2 [10]. This prevalence is dramatically greater than that reported in other epidemiological studies, which has been partly attributed to specific characteristics of the Brazilian population sample, including a higher proportion of elderly and obese [11].
Several studies have shown that OSA is very frequent in acute stroke patients and has been associated with poor short-term and long-term outcomes [12], [13], [14], [15]. In addition, OSA has been identified as an independent risk factor for stroke [6], [7], [8]. In Brazil, CVD is the leading cause of death and disability, imposing a significant economic and social burden on society [16]. A better understanding of the factors that contribute to adverse outcome of stroke patients in developing countries could guide the search for appropriate interventions to change the course of this dramatic scenario. OSA is a treatable condition and therefore its treatment seems to be a potential target to improve the outcome for acute stroke patients [17], [18], [19]. Unfortunately, there is a lack of data about the relationship between SDB and stroke patients within the Brazilian population. Furthermore, the impact of SDB on functional outcome of stroke patients is still controversial [13], [14], [20].
We sought to analyze the prevalence and severity of SDB in acute ischemic stroke patients in Brazil; to identify clinical and laboratorial data related to the presence and severity of SDB; and to assess the relationship between sleep apnea and functional outcome six months after the cerebrovascular event.
Section snippets
Subjects
Patients with first-ever supratentorial ischemic stroke within 24 h of symptoms' onset were prospectively assessed at the Emergency Department of our University Hospital. Patients with age <18 or >80 years old; stupor or coma; severe chronic obstructive pulmonary disease; clinically decompensated congestive heart failure; baseline oxyhemoglobin saturation <92%; or recent myocardial infarction were excluded. Consecutive patients who fulfilled all the inclusion criteria and none of the exclusion
Results
Sixty-nine patients were enrolled in the present study. The first 29 patients had already been reported in a previous study with a different primary objective [26]. Since then, we were able to expand our sample to improve the power of our analysis. Among all subjects, 52 (75.4%) were men, and the mean age was 60.8 ± 11.8 years. Hypertension was the most frequent risk factor for stroke (71%). History of habitual snoring was retrieved from 51 (73.9%) patients and the mean BMI was 26.3 ± 4.5 kg/m2
Discussion
We found a higher frequency of SBD in Brazilian patients with first-ever ischemic stroke with a clear predominance of obstructive events. According to the previous meta-analysis, more than 60% of stroke patients have SDB and only 7% of them have primarily central apnea [27].
The age of the patient and the hematocrit were independently associated with the presence and the severity of OSA, and BMI was also an independent predictor of severe apnea. While age and BMI are well-known risk factors for
Conflict of interest
The authors report no conflicts of interest.
The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: http://dx.doi.org/10.1016/j.sleep.2015.11.008.
Acknowledgements
The authors would like to thank Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP – 2010/04795-0, 2010/20857-5, 2012/51725-2), and Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq – 474295/2010-9, 482721/2013-8).
References (44)
- et al.
Epidemiology of sleep-related obstructive breathing
Sleep Med Rev
(2000) - et al.
Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review
Lancet Neurol
(2009) - et al.
Obstructive sleep apnea syndrome in the Sao Paulo Epidemiologic Sleep Study
Sleep Med
(2010) - et al.
Supine sleep and positional sleep apnea after acute ischemic stroke and intracerebral hemorrhage
Clinics (Sao Paulo)
(2012) - et al.
Interactions between obesity and obstructive sleep apnea: implications for treatment
Chest
(2010) - et al.
Erythropoietin and obstructive sleep apnea
Am J Hypertens
(2004) - et al.
Hematocrit levels in sleep apnea
Chest
(1994) - et al.
Sleep-disordered breathing: impact on functional outcome of ischemic stroke patients
Sleep Med
(2009) - et al.
Sleep disordered breathing in patients with acutely decompensated heart failure
Sleep Med
(2009) - et al.
Sleep apnea in patients with transient ischemic attack and stroke: a prospective study of 59 patients
Neurology
(1996)
Time course of sleep-related breathing disorders in first-ever stroke or transient ischemic attack
Am J Respir Crit Care Med
Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study
Am J Respir Crit Care Med
Obstructive sleep apnea as a risk factor for stroke and death
N Engl J Med
Association of sleep-disordered breathing and the occurrence of stroke
Am J Respir Crit Care Med
Obstructive sleep apnea-hypopnea and incident stroke: the sleep heart health study
Am J Respir Crit Care Med
International classification of sleep disorders
International classification of sleep disorders: diagnostic and coding manual
Sleep apnea in acute cerebrovascular diseases: final report on 128 patients
Sleep
Sleep-disordered breathing and acute ischemic stroke: diagnosis, risk factors, treatment, evolution, and long-term clinical outcome
Stroke
Prevalence and clinical importance of sleep apnea in the first night after cerebral infarction
Neurology
Obstructive sleep apnea is a risk factor for death in patients with stroke: a 10-year follow-up
Arch Intern Med
Past, present, and future of stroke in middle-income countries: the Brazilian experience
Int J Stroke
Cited by (26)
Increasing and high prevalence of moderate to severe obstructive sleep apnea in acute ischemic stroke in Taiwan
2024, Journal of the Formosan Medical AssociationDevelopment of a new non invasive prognostic stroke scale (NIPSS) including triage elements for sleep apnea and peripheral artery disease
2023, Journal of Stroke and Cerebrovascular DiseasesCitation Excerpt :It results in repetitive episodes of oxygen desaturation and arousals, which result in alterations in blood pressure and cerebral blood flow.16 OSA is a well-established independent risk factor for stroke17–20 and is associated with stroke recurrence21 and poor prognosis.22–24 Also, OSA is highly prevalent after stroke, reported in up to 70% of patients,22–24 and STOP-BANG is a well validated instrument for OSA screening.10
Prevalence and Determinants of Sleep Apnea in Patients with Stroke: A Meta-Analysis
2021, Journal of Stroke and Cerebrovascular DiseasesCitation Excerpt :The pooled prevalence of sleep apnea appeared to be greatest in patients with cardioembolic stroke [74.3% (59.6–85.0%)], followed by those due to large artery atherosclerosis [68.3% (52.5–80.7%)], small vessel occlusion [56.1% (38.2–72.6%)] and stroke due to other and undetermined causes [47.9% (31.6–64.6%)], although this did not reach statistical significance (I2=85%, p=0.089). Only seven studies3,16,18,25–28 (n=541) reported stroke location as supratentorial or infratentorial. The overall prevalence of sleep apnea appeared to be higher in strokes that were supratentorial in location [64.4% (56.7–71.4%)] compared with those of infratentorial in location [56.5% (42.2–60.0%)] (I2=60%, p=0.171).
Central sleep apnea is uncommon after stroke
2021, Sleep MedicineSleep as a model to understand neuroplasticity and recovery after stroke: Observational, perturbational and interventional approaches
2019, Journal of Neuroscience MethodsSafety and cost-effectiveness thrombolysis by diffusion-weighted imaging and fluid attenuated inversion recovery mismatch for wake-up stroke
2018, Clinical Neurology and NeurosurgeryCitation Excerpt :The mechanism of the unknown stroke patients is small-vessel occlusion instead of cardio embolism [14]. There are some ongoing explorations for the pathogenetic mechanism of WUS, though some reports had inconsistent evidence for risk factors [14–19,43–46]. Mechanism of pathogenesis can be divided into endogenous factors and exogenous(external) factors.