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Don’t be in the Dark about Heart Health!

February is Heart Healthy Month. 

Sleep Apnea is a Cardiovascular Disease. 

And yet, how is it possible that most medical providers today still practice medicine without considering the quality of their patient’s sleep?

Perhaps providers are thinking that  because there are ‘Sleep Specialists’, their only duty is to write a referral for their patients? However, in my experience, these referrals usually only occur when the patient straight up complains about poor sleep.

Without a solid grasp on the comorbid effects of any one of the over 100 sleep disorders out there, how are doctors going to even know which patients would benefit from such a referral?

The medical model as it exists today, has put into motion a system of evaluating symptoms with the purpose of prescribing medications. We no longer ask WHY a patient has this particular symptom. We have gotten so good with our ‘standards of care’ that we focus only on medication compliance and lifestyle modifications.

Case in point;  When updating the hypertension guidelines, this is how the academy approached the subject matter:

“We considered these the three most important questions that any doctor in America needs to know the answer to.” - American Academy of Family Physicians 

  1. At what BP do you start medication?
  2. At what BP do you maintain medication?
  3. What are the medications that doctors should use to get to goal?

 

Does it even matter WHY a person has hypertension? 

Please note the following excerpt from the American Heart Association website:

“Heart disease is the leading cause of death in the United States, 

and stroke is the No. 2  cause as well as the leading cause of disability. 

High blood pressure is a major risk factor for both.”

“The evidence is very strong for the relationship between

sleep apnea and hypertension and cardiovascular disease generally, 

so people really need to know that.” -- Donna Arnett, PhD., President of the American Heart Association. 

“One in five adults suffers from at least mild sleep apnea, and it affects more men than women,” Dr. Arnett continues.

The Center for Disease Control also stresses the following facts:

“Persons with sleep apnea have been found to be at

increased risk for a number of cardiovascular diseases. 

Notably, hypertension, stroke, coronary heart disease

and irregular heartbeats (cardiac arrhythmias) 

have been found to be more common

among those with disordered sleep

than their peers without sleep abnormalities.

Likewise, sleep apnea and hardening of the arteries (atherosclerosis)

appear to share some common physiological characteristics, 

further suggesting that sleep apnea may be

an important predictor of cardiovascular disease.”2

 

If this knowledge is abundantly available from several respected sources, then why isn’t it being routinely addressed? 

If, as the CDC clearly states, “sleep apnea may be an important predictor of cardiovascular disease”, then why are we not routinely screening for sleep apnea? Your blood pressure is checked at each point of medical contact to screen for hypertension (cardiovascular disease). 

How often would it be prudent to test for sleep apnea?

Prevention is the goal, is it not? Or have we only become interested in prescribing medication?

As a provider, ask yourself, “Of all the patients on my roster that have been diagnosed with hypertension, how many have had sleep tests and are successfully being treated for sleep apnea (or other sleep disorders)?

Does this problem rest solely with family physicians?

Surely internal medicine doctors, who look at the whole patient rather than just one area, like cardiology etc, would be on top of sleep disorders -  especially sleep apnea, right?

Well consider the following scenario;

An internal medicine doctor assesses a patient with congestive heart failure, shortness of breath, diabetes, bilateral lower extremity pitting edema, obesity, high blood pressure and now is starting with kidney failure. He orders a larger dose of a diuretic and tells the patient they are going to be discharged. 

The patient inquires, “I was told that taking larger doses of diuretics will damage my kidneys more. What else can I do Doc?”

Doc begins to walk away, “Lose weight.” 

She calls after him, “How am I supposed to do that when I am so exhausted? I can’t sleep. Every time I fall asleep, I wake up choking.”

He calls back over his shoulder, “Eat less today, than you did yesterday!”

Not only is the patient shamed in front of the rest of the emergency department, but I see hope drain from her face. So this is it for her?

I follow him into the charting room and ask him, “Doctor, do you think this patient may have Obstructive Sleep Apnea?”

“Of course she does...they all do! Do you know how many patients we see each day have sleep apnea?!” is his reply.

“Exactly,” I respond, “So what are we going to do for them? Are you going to refer her for a sleep test? How can we get all these folks tested and treated?”

“She can follow up with her family doctor. Besides, we don’t have any local sleep labs.”

“You are an internist. Can you not use her symptoms along with the vitals and apneic events I can show you since I’ve been monitoring her, and send her home with an APAP until she can get into the lab for a PSG?”

“I used to do that years ago, but people complain about wearing the machines so I don’t bother anymore.”

“Ok, but CPAPs have changed so much over the years, they’re vastly improved and the masks are so much more pleasant to wear. And then there are oral appliances…”

“Do those things really work?” he interrupts.

“Yes, there are so many studies proving efficacy and compliance, I can show you if you like…”

“Do you know the costs involved with testing and treating all the people that actually have sleep apnea?" he interrupts, "It would be huge! And do you know what the government does when it doesn’t want to foot the bill? It makes it unavailable or very difficult to obtain.”

“But, they are paying for it!” I object, “They are paying for ER visits, hospitalizations, surgeries medications, lost time at work, disabilities, accidents that could be prevented, lives that would be greatly improved if they would just treat patients’ sleep!”

“Well anyway, you gotta be a pulmonologist or respirologist to order all that stuff.”

He dismisses me. 

I go back to the patient and beg her to talk with her family doctor and ask for a sleep test, but I can tell by the look in her eyes she’s given up.

 

Who are we helping by turning a blind eye to this epidemic?

The medical community pats themselves on the back for identifying hypertension and smacking it all over with medications. Is anyone actually getting healthier from these all these medications? If not, I guess we have gotten used to comforting ourselves with the perverse thought that if the patient is not improving it is likely their own fault because they are probably non-compliant with their meds, overweight, overstressed, don’t exercise, are drawn to high fat, high sugar food and so on. It couldn’t possibly be that we never addressed the underlying issue that is causing their high blood pressure in the first place - adrenergic surges from a lack of oxygen during sleep, insufficient and inefficient sleep.

 

The medical community is not connecting current science with standards of care in a practical way that helps the patient today. 

Here’s a perfect example;  the Hypertension Guidelines state:

“For all persons with hypertension, the potential benefits of

a healthy diet, weight control, and regular exercise

cannot be overemphasized. 

These lifestyle treatments have the potential to

improve BP control and even reduce medication needs. 

Although the authors of this hypertension guideline

did not conduct an evidence review of lifestyle treatments

in patients taking and not taking antihypertensive medication, 

we support the recommendations of the 2013 Lifestyle Work Group.” 

Why is it that we never get tired of telling our patients that they need to make ‘lifestyle changes,’  exercise, lose weight and make significant dietary changes, even though they rarely do? But we are too tired to talk to them about sleep apnea because some patients have had difficulty following through with recommended treatment? Did we offer alternatives? 

Is it because one puts all the onus on the patient and the other requires that WE have to accept the responsibility to work with our patients to help them achieve restorative sleep, which in turn, helps them to have more control over their daily life and actually be able to make better lifestyle choices?

We are ok to shame and blame our patients, but cannot handle our own feelings of professional inadequacy? Do we not feel knowledgeable about the subject? Have we taken the time to learn more? Attend continuing education courses to be better prepared to help our patients? Or are we content to practice based on the limited 20 - 40 minutes of exposure we received during our formal education?

It is time for us to take a complete history and physical. We can no longer ignore that elusive one-third of our patients’ lives! What happens during sleep definitely has an effect on how our patients function during the day. Ignoring this could cause us to unwittingly do more harm than good, by prescribing sleeping pills for insomnia for example, without accurately assessing airway, oxygenation and sleep staging, we could be further exacerbating their restorative sleep deficit.

 

Don’t stay in the dark when it comes to your patients’ sleep. 

Their heart health depends on it!

Julia Worrall