Patients with stroke should receive screening for sleep apnea in the short-term event period, receiving treatment with continuous positive airway pressure.
Dawn Bravata, MD, Regenstrief Institute investigator, Indiana School of Medicine
Dawn Bravata, MD
A new study discovered that beginning continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea (OSA) as soon as possible after an ischemic stroke or transient ischemic attack occurs, significantly improves neurological symptoms and physical functioning.
The study’s lead investigator, Dawn Bravata, MD, Regenstrief Institute, Inc., told NeurologyLive that while many key questions remain unanswered, there’s 2 that are most important to the team’s mission. First and foremost, Bravata noted is the importance of understanding how hospitals should organize care so stroke patients can receive polysomnography and CPAP as soon as possible after an index stroke or transient ischemic attack.
“Our study suggests that we need to create acute sleep medicine programs that can provide diagnostic and treatment services in the inpatient setting. One approach that some investigators have used in prior studies is the direct application of auto-titrating CPAP which can be used both diagnostically and therapeutically and which obviates the need for polysomnography,” the Core Investigator, VA Health Services Research and Development Center for Health Information and Communication, Roudebush VA Medical Center said. “Second, we do not know what the minimum necessary CPAP dose is to achieve maximal neurological recovery. In the private sector, insurance companies provide CPAP machines only to patients who use them a certain number of hours per night. Our data suggest that any CPAP use is better than no CPAP use, therefore, we must establish a dose-response relationship among patients with stroke and transient ischemic attack in order to inform health care policy.”
The randomized controlled trial followed individuals from 5 hospitals in 2 states who had strokes or transient ischemic attacks for up to 1 year after the attack. Of the 252 study participants, two-thirds were able to use CPAP effectively. Study participants were randomized to a control group (usual care) (n=84) without sleep apnea treatment or to 1 of 2 intervention strategies, standard (n=86) or enhanced (n=82), for the diagnosis and treatment of OSA. The enhanced protocol focused on delivering the patient-tailored behavioral adherence program, while the standard protocol focused on technical issues related to CPAP equipment. Among the patient population, the prevalence of OSA was as follows: control 69%; standard 74%; and enhanced 80%. Primary outcomes included the National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) scores.
Even though changes in neurological function and functional status were similar across both groups in the intent-to-treat analyses, use of CPAP was associated with improved neurological function among patients with acute ischemic stroke and transient ischemic attack with OSA. The observed changes in the NIHSS were modest and similar across all groups: control, -0.5±2.1; standard, -0.8±1.9; enhanced, -0.7±2.1 (P = .80), but changes in the mRS score were not statistically different across the 3 groups: control, 0.1±1.5; standard, -0.6±1.2; enhanced, -.03±1.5 (P = .60).
In as‐treated analyses among patients with OSA, increasing CPAP use was associated with improved NIHSS score (no/poor, −0.6±2.9; some, −0.9±1.4; good, −0.3±1.0; P=0.0064) and improved mRS score (no/poor, −0.3±1.5; some, −0.4±1.0; good, −0.9±1.2; P=0.0237).
More than 70% of the intervention participants with sleep apnea had some or good CPAP use, suggesting that it’s feasible to provide CPAP therapy to patients with cerebrovascular disease. Median CPAP use per night was 4.5 hours for both standard and enhanced patients, but the enhanced protocol did not improve long-term CPAP adherence when compared with standard protocol.
Study results demonstrate that CPAP therapy for patients with stroke who have sleep apnea was associated with statistically significant and clinically relevant improvements in both neurological symptoms and functional status, adding to previously found evidence supporting the diagnosis and treatment of sleep apnea early after a stroke event.
Despite national stroke guidelines recommendation of testing for sleep apnea, observational studies have shown it’s not being widely implemented. These data support routine use of polysomnography for all patients with an ischemic stroke or transient ischemic attack.
J, Vaz Fragoso C, et al. Diagnosing and Treating Sleep Apnea in Patients With Acute Cerebrovascular Disease. Journal of the American Heart Association. 2018;7.