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
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.
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?
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/
Mar 3·edited Mar 3Liked by The Skeptical Cardiologist
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.
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
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
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?
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.
First rate info