The sleep apnea industry would like you to believe that it does but high quality data show that CPAP is ineffective in improving cardiovascular outcomes for most individuals
SleepHQ.com, bought the ring pulse ox, bought the Magic Uploader, bought the premium plan ($150/yr), bought a better mask (Lena by Lowenstein from German) and more data than you can shake a stick at if you have patients and friends struggling with this therapy. I want to know what’s going on when I’m asleep. Now I’ve got some important data. A far cry from the paltry Phillips Respironics or ResMed machine info. Sleep study level data. Which I will take to my sleep study tonight.
There is a knee-jerk response in the EP community to recommend a sleep study to patients with atrial fibrillation, even if the patient has no clinical symptoms related to disturbed sleep.
Sleep studies will detect abnormalities that are clinically meaningless.
Congrats on losing those pounds!
I think that is doing much more for your long term cardiovascular health than anything related to sleep apnea.
Interesting! I’ve had two known episodes of AFIB (2016 and 2022). A sleep study suggested I had mild apnea, and one MD suggested a CPAP. I declined, as I am the polar opposite of the textbook apnea sufferer. I’m quick to fall asleep, don’t snore much, sleep blissfully, wake up energized w/o an alarm, am not sleepy during the day. I didn’t wish to compromise these happy circumstances by loading my head down with some bulky contraption. Fortunately, my other MDs concurred that it was not called for. (I did lose 35-40 pounds after the diagnosis—partly out of prudence and perhaps even more out of vanity.)
thanks for sharing your experience. I have a few afib patients who consistently note its onset during sleep. For them I consider that OSA might be a significant trigger. In my experience, if OSA diagnosed when the only indication was nocturnal afib, CPAP therapy rarely improves afib frequency. I also have lots of patients with OSA for in whom afib does not come on during sleep.
I've never done a sleep lab test but I can guarantee my sleep would be horrific. I'd definitely prefer an at home test.
the Zio (if competently over read by a good cardiologist) is very accurate at afib if duration >30 seconds or so.
Why did you get a Zio initially?
Apple Watch is also very good at picking up rest episodes of tachycardia. Most of patients who don't feel their afib have it accurately identified by AW
So, I suspect you are having less episodes.
IMHO, docs should not specialize in one disease. They become too dependent on making that diagnosis, inflating the importance of the diagnosis, treating that diagnosis, and spreading the disease to those who don't have it.
I'm a 75 yr old man in excellent overall health except for BPH and BMI of 27. All labs are WNL including a CAC of Zero; & not Hx of heart disease in my family. I got the Zio initially because I detected detected multiple episodes of tachycardia (HR 130-155) last fall. The 1st time I noticed it I was on a vigorous walk. When I stopped my HR stayed over 130 for almost an hour (generally it drops in 3-5 mins). Then I noticed several more episodes of TC that occurred while not exercising and lasted 20-40 mins. I had no other symptoms and BP was normal. But I am a retired DVM and very proactive so I got an appt with a cardio (my 1st one).
As a side note, we have a good family friend who is a retired Cardio Prof at U WA who said the mantra among cardios is "once an Afiber, always an Afib". I hope to buck that trend!
I discovered you blog while researching AF and it helped me decide to get the AW. I'm enjoying your posts. Incidentally my wife also has AF (3% burden) and reduced LVEF of 35-40.
This was fantastic, and answers a lot of questions I was thinking about doing another post on as well! Great summary statement at the end, well documented and supported.
There is absolutely no doubt in my mind that it has improved my overall health, helped me control my weight, and has efficiently prevented any recurrence of quite severe atrial flutter (after unsuccessful catheter ablation in 18-08). And this whole great improvement has lasted now for almost 6 years. My compliance with CPAP is 100%. My SaO2 which was, on average, 85-88% before therapy, is now always normal. (I am discounting AHI counts because they really are not very well standardized, nor really a valid clinical end-point).
I am becoming somewhat angry at the developing general skepticism in Medicine. There IS room for questioning the quality of most clinical studies, but what really makes me angry is the apparent inability of medical research to develop and implement good-quality studies of a problem such as OSA and apnea therapy, even if a clinical problem is not amenable to a full-on RCT!
It's just too easy to adopt the high-ground of skepticism and criticism, but FAR more difficult to design an appropriate study!
I am reminded of the joke about the absence of a randomized controlled trial of parachutes… But I don't find it funny anymore.
Bravo!!! The sleep medicine is the worst case of pseudo science ever. Cardiovascular problems were used to scare people but they do have the merit of keeping those partially true statements accepted for such a long period of time.
"the American health care system has joined with commercial partners to define a medical condition — in this case, sleep apnea — in a way that allows both parties to generate revenue from a multitude of pricey diagnostic studies, equipment sales, and questionable treatments. I was on a conveyor belt."
I'm thinking the rationale is that if you are not compliant with CPAP then you are at an increased risk of daytime sleepiness and therefore at an increased risk of causing an accident.
Have you investigated how this was initiated.
it seems like a horrible case of unnecessary intrusion of bureaucracy into private life.
I have sleep apnea and use CPAP. I recently had a stressful experience. I live in Maryland and I recently moved. I went online to change my address on my driver's license. I reached a screen on which a number of medical conditions were listed, including sleep apnea. I was asked if I had any of these conditions. I said yes. I received some forms in the mail that required me and my doctor to fill out questionnaires. My doctor said I was compliant with CPAP and she had no concerns with my driving. This was not sufficient -- the MVA demanded the print-out from my CPAP. After reviewing the report, they approved my continuing to drive. The whole process was quite intimidating as each letter threatened yanking my license if the requested information were not provided by a certain date. Thoughts?
I can understand jumping through those hoops if you checked narcolepsy but for sleep apnea? Likely a legislator had a reason ( not saying reasonable) or experience to make that their pet project for vehicle regulation.
This was interesting! I do think with so many older adults with type two diabetes the sleep CPAP increases sleep which directly affects blood sugars during the day. That makes it worthwhile but your point on cardio health is well taken.
Thanks so much for your work, Dr. Pearson. You mention the difficulty of finding OSA authorities who will be frank about industry claims. In writing this 2022 piece for KHN, I found that European scientists (removed from industry $$$ and AASM influence) are quite helpful and credible on this. (Not to mention their pointing out that AASM standards for diagnosing OSA are arbitrary & nuts.) https://kffhealthnews.org/news/article/severe-sleep-apnea-diagnosis-panics-reporter-until-he-finds-a-simple-no-cost-solution/
Now a new study has concluded: "Greater CPAP levels increase proinflammatory, lung distension-responsive angiopoietin-2 and reduce cardioprotective angiogenic factor VEGF-A compared to usual care, which may counteract the expected cardiovascular benefits of treating OSA." (link #1) Now I don't know whether to tell this to 2 of my relatives who say they feel SO much better during the day since they got their CPAP! Maybe they can try Inspire unless that's just more marketing... (link #2)
Thank you very much for yet another great article. I was misdiagnosed with sleep apnea about a decade ago. Although I had my suspicions at the time, I went along with CPAP and, after that proved to be too troublesome (and stress-inducing!) switched to a dental appliance. I finally decided to find an doc who was willing to arrange to have sleep tracking equipment sent to me for a retest in my own bed instead the awful sleep lab. Result after two nights of sleep tracking: no apnea. I am deeply skeptical of this industry, to put it mildly.
Three months ago I was diagnosed with 4% AFib burden (rate 120-150), 70% of episodes occurring during sleeping hours (Zio 14 day monitor). Since so many AF episodes occurred during sleep, I started to look in OSA as a possible cause even though I am not at all tired during the day. But I'm 75 & my wife says I snore! Thank you thank you for pointing out those two factors alone place me in the "High Risk" category
After my initial Zoom interview with a local SA Dr, she was alarmed and said I needed to get into the sleep lab ASAP (1st opening 3 months from now -- either these are get folks funneled into the by the hordes or severely understaffed or both). I asked about the 2 day home test, she reluctantly approved that. That is still over 2 months off. Thank you for this article as it will help me go into the OSA testing with my eyes wide open (figuratively speaking).
BTW, since I am still hike a lot and bike I decided to take my chances with the 4% AF burden & not take anti-coags not B blockers. Interestingly I got an Apple 9 watch after my Holter test. Over the past two months, the watch has not shown an single episode of tachycardia during sleep. Meanwhile the watch is correlates very well with my BP cuff and Pulse Ox at rest and during strenuous exercise. Now I'm wondering how accurate the Zio monitor was??? Or is it the watch???
SleepHQ.com, bought the ring pulse ox, bought the Magic Uploader, bought the premium plan ($150/yr), bought a better mask (Lena by Lowenstein from German) and more data than you can shake a stick at if you have patients and friends struggling with this therapy. I want to know what’s going on when I’m asleep. Now I’ve got some important data. A far cry from the paltry Phillips Respironics or ResMed machine info. Sleep study level data. Which I will take to my sleep study tonight.
I think what you encountered is typical.
There is a knee-jerk response in the EP community to recommend a sleep study to patients with atrial fibrillation, even if the patient has no clinical symptoms related to disturbed sleep.
Sleep studies will detect abnormalities that are clinically meaningless.
Congrats on losing those pounds!
I think that is doing much more for your long term cardiovascular health than anything related to sleep apnea.
Interesting! I’ve had two known episodes of AFIB (2016 and 2022). A sleep study suggested I had mild apnea, and one MD suggested a CPAP. I declined, as I am the polar opposite of the textbook apnea sufferer. I’m quick to fall asleep, don’t snore much, sleep blissfully, wake up energized w/o an alarm, am not sleepy during the day. I didn’t wish to compromise these happy circumstances by loading my head down with some bulky contraption. Fortunately, my other MDs concurred that it was not called for. (I did lose 35-40 pounds after the diagnosis—partly out of prudence and perhaps even more out of vanity.)
I will republish it. Perhaps with some follow up on the patient. How is your OSA doing these days?
Daniel,
thanks for sharing your experience. I have a few afib patients who consistently note its onset during sleep. For them I consider that OSA might be a significant trigger. In my experience, if OSA diagnosed when the only indication was nocturnal afib, CPAP therapy rarely improves afib frequency. I also have lots of patients with OSA for in whom afib does not come on during sleep.
I've never done a sleep lab test but I can guarantee my sleep would be horrific. I'd definitely prefer an at home test.
the Zio (if competently over read by a good cardiologist) is very accurate at afib if duration >30 seconds or so.
Why did you get a Zio initially?
Apple Watch is also very good at picking up rest episodes of tachycardia. Most of patients who don't feel their afib have it accurately identified by AW
So, I suspect you are having less episodes.
IMHO, docs should not specialize in one disease. They become too dependent on making that diagnosis, inflating the importance of the diagnosis, treating that diagnosis, and spreading the disease to those who don't have it.
dr P
I'm a 75 yr old man in excellent overall health except for BPH and BMI of 27. All labs are WNL including a CAC of Zero; & not Hx of heart disease in my family. I got the Zio initially because I detected detected multiple episodes of tachycardia (HR 130-155) last fall. The 1st time I noticed it I was on a vigorous walk. When I stopped my HR stayed over 130 for almost an hour (generally it drops in 3-5 mins). Then I noticed several more episodes of TC that occurred while not exercising and lasted 20-40 mins. I had no other symptoms and BP was normal. But I am a retired DVM and very proactive so I got an appt with a cardio (my 1st one).
As a side note, we have a good family friend who is a retired Cardio Prof at U WA who said the mantra among cardios is "once an Afiber, always an Afib". I hope to buck that trend!
I discovered you blog while researching AF and it helped me decide to get the AW. I'm enjoying your posts. Incidentally my wife also has AF (3% burden) and reduced LVEF of 35-40.
I have seen a number of one and done fibbers and many in whom anti-arrhythmic therapy eliminated the AFIB so disagree with "always an afibber" mantra.
That's encouraging, FYI, mine seems to have ceased without taking any meds.
My wife on the other had started Metoprolol ER 50 mg & Xarelto 20, both SID and has had no AF episodes since per her AW.
When & how often do you advise going of anti-arrhythmic therapy to determine if they are necessary to control AF?
This was fantastic, and answers a lot of questions I was thinking about doing another post on as well! Great summary statement at the end, well documented and supported.
My life was radically changed by CPAP therapy!
There is absolutely no doubt in my mind that it has improved my overall health, helped me control my weight, and has efficiently prevented any recurrence of quite severe atrial flutter (after unsuccessful catheter ablation in 18-08). And this whole great improvement has lasted now for almost 6 years. My compliance with CPAP is 100%. My SaO2 which was, on average, 85-88% before therapy, is now always normal. (I am discounting AHI counts because they really are not very well standardized, nor really a valid clinical end-point).
I am becoming somewhat angry at the developing general skepticism in Medicine. There IS room for questioning the quality of most clinical studies, but what really makes me angry is the apparent inability of medical research to develop and implement good-quality studies of a problem such as OSA and apnea therapy, even if a clinical problem is not amenable to a full-on RCT!
It's just too easy to adopt the high-ground of skepticism and criticism, but FAR more difficult to design an appropriate study!
I am reminded of the joke about the absence of a randomized controlled trial of parachutes… But I don't find it funny anymore.
Bravo!!! The sleep medicine is the worst case of pseudo science ever. Cardiovascular problems were used to scare people but they do have the merit of keeping those partially true statements accepted for such a long period of time.
That is an outstanding article!
Great quote :
"the American health care system has joined with commercial partners to define a medical condition — in this case, sleep apnea — in a way that allows both parties to generate revenue from a multitude of pricey diagnostic studies, equipment sales, and questionable treatments. I was on a conveyor belt."
Looks KHN allows me to republish it....
Dr P
thanks! KHN content is free/ available for anybody to republish
CPAP improves sleep quality for some but I've talked to dozens of patients who have a terrible time sleeping with the device.
You'd have to do a randomized trial to determine whether it improves diabetic control or not.
That is insane and terrifying!
I'm thinking the rationale is that if you are not compliant with CPAP then you are at an increased risk of daytime sleepiness and therefore at an increased risk of causing an accident.
Have you investigated how this was initiated.
it seems like a horrible case of unnecessary intrusion of bureaucracy into private life.
We should write about it.
Dr P
I have sleep apnea and use CPAP. I recently had a stressful experience. I live in Maryland and I recently moved. I went online to change my address on my driver's license. I reached a screen on which a number of medical conditions were listed, including sleep apnea. I was asked if I had any of these conditions. I said yes. I received some forms in the mail that required me and my doctor to fill out questionnaires. My doctor said I was compliant with CPAP and she had no concerns with my driving. This was not sufficient -- the MVA demanded the print-out from my CPAP. After reviewing the report, they approved my continuing to drive. The whole process was quite intimidating as each letter threatened yanking my license if the requested information were not provided by a certain date. Thoughts?
I can understand jumping through those hoops if you checked narcolepsy but for sleep apnea? Likely a legislator had a reason ( not saying reasonable) or experience to make that their pet project for vehicle regulation.
This was interesting! I do think with so many older adults with type two diabetes the sleep CPAP increases sleep which directly affects blood sugars during the day. That makes it worthwhile but your point on cardio health is well taken.
Thanks so much for your work, Dr. Pearson. You mention the difficulty of finding OSA authorities who will be frank about industry claims. In writing this 2022 piece for KHN, I found that European scientists (removed from industry $$$ and AASM influence) are quite helpful and credible on this. (Not to mention their pointing out that AASM standards for diagnosing OSA are arbitrary & nuts.) https://kffhealthnews.org/news/article/severe-sleep-apnea-diagnosis-panics-reporter-until-he-finds-a-simple-no-cost-solution/
Now a new study has concluded: "Greater CPAP levels increase proinflammatory, lung distension-responsive angiopoietin-2 and reduce cardioprotective angiogenic factor VEGF-A compared to usual care, which may counteract the expected cardiovascular benefits of treating OSA." (link #1) Now I don't know whether to tell this to 2 of my relatives who say they feel SO much better during the day since they got their CPAP! Maybe they can try Inspire unless that's just more marketing... (link #2)
https://www.thelancet.com/journals/ebiom/article/PIIS2352-3964(24)00050-1/fulltext
https://www.inspiresleep.com/en-us/?gad_source=1&gclid=CjwKCAiA3JCvBhA8EiwA4kujZoC6YjLqT9azIaE_0UlXwUTI47q1SgVR_4NbKIqlznxErZR15jEjkRoCJxYQAvD_BwE
Thank you very much for yet another great article. I was misdiagnosed with sleep apnea about a decade ago. Although I had my suspicions at the time, I went along with CPAP and, after that proved to be too troublesome (and stress-inducing!) switched to a dental appliance. I finally decided to find an doc who was willing to arrange to have sleep tracking equipment sent to me for a retest in my own bed instead the awful sleep lab. Result after two nights of sleep tracking: no apnea. I am deeply skeptical of this industry, to put it mildly.
Three months ago I was diagnosed with 4% AFib burden (rate 120-150), 70% of episodes occurring during sleeping hours (Zio 14 day monitor). Since so many AF episodes occurred during sleep, I started to look in OSA as a possible cause even though I am not at all tired during the day. But I'm 75 & my wife says I snore! Thank you thank you for pointing out those two factors alone place me in the "High Risk" category
After my initial Zoom interview with a local SA Dr, she was alarmed and said I needed to get into the sleep lab ASAP (1st opening 3 months from now -- either these are get folks funneled into the by the hordes or severely understaffed or both). I asked about the 2 day home test, she reluctantly approved that. That is still over 2 months off. Thank you for this article as it will help me go into the OSA testing with my eyes wide open (figuratively speaking).
BTW, since I am still hike a lot and bike I decided to take my chances with the 4% AF burden & not take anti-coags not B blockers. Interestingly I got an Apple 9 watch after my Holter test. Over the past two months, the watch has not shown an single episode of tachycardia during sleep. Meanwhile the watch is correlates very well with my BP cuff and Pulse Ox at rest and during strenuous exercise. Now I'm wondering how accurate the Zio monitor was??? Or is it the watch???