Is Snoring a Stroke Risk?
How Snoring Hurts Your Heart
Why Snoring Matters
It may seem somewhat surprising, but for most people who develop atrial fibrillation, their doctor will ask about their sleep. A typical conversation for me will go like this:
“Do you snore?”
The patient will respond, “I don’t believe I snore. Maybe a bit, when I'm very sleepy.”
For a male patient, I will ask his wife, if she's with him, “Does your husband snore at night?”
She will often say, “If I don’t get to sleep before him, I can’t, because he snores so loudly.”
Or, “We sleep in separate rooms and I can still hear him.”
In some cases, “His snoring is so bad we have fortified the walls to stop them from falling down.”
My favorite response, from an elderly woman, was, “He doesn’t snore at all since I started wearing ear plugs at night.”
The disorder we physicians are looking for with this line of questioning is called sleep apnea. This is a sleep-related disorder where the body oxygen levels fall during sleep. There are two main types of sleep apnea. You can suffer from both types at the same time.
- Obstructive sleep apnea: This is the most common form. It occurs when the throat muscles relax and the tissues of the throat then obstruct airflow. During partial obstruction, a person can be heard snoring.
- Central sleep apnea: This form is less common and often develops when other diseases may be present or with certain medications. In this disorder, the brain stops sending signals to the body muscles to breathe. This can be a completely silent problem. Sometimes spouses will notice their partner’s breaths become soft, and then absent, for short times.
How Do You Know if You Have Sleep Apnea?
One of the most important aspects of sleep apnea is that it occurs when you are in deep enough sleep for the throat muscles and brain to relax. In this regard, the person with sleep apnea typically does not recognize that it is occurring. At times, people will awaken when the apnea becomes so severe the sleeping mind and body panic.
If anything, waking from sleep apnea suggests that it may be quite severe. Most people only recognize the side effects of sleep apnea.
Side effects of sleep apnea can include:
This list of problems, many of which can be life altering, highlight the need to identify and treat sleep apnea.
When physicians check sleep patterns amongst all people with atrial fibrillation, sleep apnea can be diagnosed 30 percent to 50 percent of the time. In people who have atrial fibrillation and one or more of the side effects listed above, the chances are much higher that they have sleep apnea. In medicine, sometimes screening tests can be invasive, time-consuming, and costly. But for sleep apnea, the upfront screening tool we use in our clinic is quite simple. It is called the STOP-Bang questionnaire.
Take the 'Sleep Quiz'
The STOP-Bang questions to identify sleep apnea include:
- Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?
- Do you often feel tired, fatigued, or sleepy during daytime?
- Has anyone observed you stop breathing during your sleep?
- Do you have, or are you being treated for, high blood pressure?
- Is your body mass index (BMI) higher than 35?
- Are you over 50 years old?
- Is your neck circumference greater than 40cm (16 inches)?
- Are you male?
Answering "yes" to three or more of these questions, may indicate the need for additional testing. Even if you score less than three, additional testing may be needed. This is particularly true if you are seen with a disease very commonly associated with sleep apnea, such as atrial fibrillation.
Why Are Screening and Treating Sleep Apnea so Essential?
The simple answer is that sleep apnea is one of the greatest causes of atrial fibrillation. Not only does it cause atrial fibrillation, it worsens its severity. It does this by increasing the areas of the upper heart chambers that drive and maintain the abnormal heart rhythm.
To a patient, this increase in disease severity can be noticed when the abnormal heart rhythm no longer responds to medications, requires electrical shocks called cardioversions to restore normal rhythms, or when a seemingly successful catheter ablation procedure fails to prevent recurrent atrial fibrillation.
The importance of sleep apnea diagnosis and treatment as a means to improve atrial fibrillation treatment was reinforced in a recently published meta-analysis of atrial fibrillation patients.
The study included seven clinical trials with patients who received drug management for their atrial fibrillation as well as patients who had catheter ablation. The effect of sleep apnea treatment on abnormal heart rhythm was investigated for 1,087 of these patients.
In summary, the authors found:
- Patients who were treated for sleep apnea were 42 percent less likely to have their atrial fibrillation recur.
- In people who received a catheter ablation for their atrial fibrillation, those who had sleep apnea and were treated for it were, again, 42 percent less likely to develop recurrent atrial fibrillation.
- In people who used medications alone for treatment of their atrial fibrillation, the same outcome was found. Those who had sleep apnea, and were treated, were 42 percent less likely to have recurrence of atrial fibrillation.
Even with our most aggressive treatment strategy for atrial fibrillation, when sleep apnea goes untreated, the approach does not work well. Untreated sleep apnea lowers overall success rates by approximately 25 percent. For example, most treatment centers will quote you success rates with ablation from 50 percent to 75 percent, based upon the type of atrial fibrillation you have. But if you have sleep apnea that is untreated, the sobering fact is that you need to consider long-term success rates of only 25 percent to 50 percent.
Many people ask me how long their medication will work, in hopes that they won't have to use a riskier medication, or undergo an invasive procedure. In this study, if the patients did not treat their sleep apnea, 63 percent had recurrence of their atrial fibrillation within a year.
What to Do About Sleep Apnea
I general, if you score high on the STOP-Bang questionnaire, seek evaluation and treatment for sleep apnea. Sleep apnea is a disorder you cannot ignore. It will expose you to multiple diseases that can significantly reduce your quality of life, and in some cases, shorten your life.
If you have atrial fibrillation, regardless of how you treat it, evaluation and treatment for sleep apnea will improve how you respond and how you feel.
Finally, if you already have sleep apnea but are not being treated, these same lessons and concepts apply to you. I would encourage you to revisit treatment options with a sleep specialist. There are many different treatment options that can be tailored to your needs. If you find yourself without an acceptable treatment that you can tolerate, consider the risk factors included in the STOP-Bang questionnaire. Some of these can be modified. Those include your neck circumference, your weight, and your blood pressure.
T. Jared Bunch, MD is a native of Logan, Utah, and directs heart rhythm research at the Intermountain Medical Center Heart Institute. You can follow @TJaredBunch on Twitter. Dr. Bunch is also a frequent guest on The Dr. John Day Show, available on iTunes.
Photo: Jose Luis Pelaez/Getty
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