VARIABILITY IN HIGH BLOOD PRESSURE PREDICTS FUTURE STROKES. NEW SLEEP APNEA TREATMENT PROTOCOLS NEEDED TO REFLECT THIS DANGER

Patients with fluctuating high blood pressure are at greater risk of stroke than patients with consistently high blood pressure. A frequent cause of elevated blood pressure (hypertension) is untreated sleep apnea. Patients with untreated sleep apnea frequently have wide swings in blood pressure at night and will often have high blood pressure in early morning readings. The current blood pressure guidelines look only at average blood pressure when considering medical risks.

The Lancet published the first in a series of articles in which researchers from the UK and Swedish evaluated variability in blood pressure readings at routine doctors’ visits and the relation to risk of stroke.

According to Professor Peter Rothwell the study leader, patients with fluctuating readings during various physician visits faced the greatest risk of future stroke. This was true regardless of average blood pressure readings.

Beta blockers, according to a study in The Lancet Neurology increased variability in patient’s blood pressure.
Dr Rothwell explains “What we’re saying is don’t discount that one-off high blood pressure reading.” Medications will now be evaluated not only for reducing average blood pressure readings but also for controlling blood pressure variability with periodic high readings.

Sleep apnea is a major cause of elevated blood pressure and is frequently untreated or under-treated according to Dr Ira L Shapira, a Diplomate of the American Board of Dental Sleep Medicine and founder of the website www.ihatecpap.com. “The dirty secret in Sleep Medicine is that the majority of patients do not treat their sleep apnea on a cosistent basis with CPAP.” CPAP, or continuous positive air pressure is considered the “Gold Standard” of treatment for sleep apnea but only about 1 in 4 patients use their CPAP all night every night. CPAP is excellent and effective treatment when it is used consistently all night long. A recent study showed that 60% of patients abandon CPAP use completely and other studies have shown that the majority of patients who utilize CPAP average only 4-5 hours a night and only 4 nights a week not the recommended 7-7 1/2 hours seven nights a week..

This type of CPAP use will tend to create greater swings in patients blood pressure on a day to day basis! This is exactly what the new study finds to be a major risk for strokes.

An even more alarming fact about CPAP treatment is that strokes most commonly occur in the early morning hours. Patients who only use their CPAP for 4-5 hours have already quit using their CPAP machines before the time of night with the highest risk of strokes and heart attacks. Oral appliances offer a comfortable alternative to CPAP that are preferred by a majority of patients offered a choice of therapies. (see http://www.sleepandhealth.com/oral-appliances-vrs-cpap-shapira) The website http://www.ihatecpap.com is an excellent source of information about oral appliances and treatment of CPAP utilizing Dental Sleep Medicine. While they offer a more comfortable and better tolerated alternative to CPAP they are not a panacea.

Oral appliances are not always able to completely eliminate all apneic events but they are usually preferred by patients and have far fewer compliance issues. Patients frequently state they feel better with oral appliance therapy even though CPAP was more successful in eliminating apneic events. This may be because increased patient compliance leads regular and cosistent treatment of apnea and secondarily to more even keeled blood pressure control .

A study should be done as soon as possible to determine whether the time of day blood pressure is taken is a key factor in the variability of blood pressure that predicts the occurence of more strokes. On and off use of CPAP that leads to increased swings of blood pressure may actually be a severe risk factor for stoke. Medicare has instituted new guidlines for CPAP coverage that set minimum levels of usage for medicare to pay for the CPAP treatment. This is because Medicare has recognized the financial burdens to the system from CPAP units that are not being used regularly if at all. The cost of increased medical expenses by on and off use CPAP should also be carefully evaluated.

The American Academy of Sleep Medicine now recognizes Dental Sleep Medicine and oral appliances as a first line treatment for mild to moderate sleep apnea (along with CPAP) and a secondary alternative treatment for severe apnea when patients do not tolerate CPAP. A recent study has shown that oral appliances can be very effective in treating severe obstructive sleep apnea.

In patients with severe apnea and only part time use of CPAP should oral appliance therapy be considered a first line treatment if used nightly with a significant reduction in apnea if blood pressure readings are more stable? This would be a major change in the current protocols.

The best treatment for the 60% of patients who do not use CPAP at all is an oral appliance. Surgery would be an alternative treatment for the minority of patients when CPAP and/or oral appliances are not tolerated.

All patients who have only part-time use of CPAP should be advised that utilization of an oral appliance when they are not using CPAP would probably be beneficial to their overall health and would reduce both strokes and cardiac events.

Airway Management is the manufacturer of the TAP appliances, the most effective oral appliances available primarily due to ease of titration. They have recently released their new TAP-PAP combination of CPAP and an oral appliance. The added comfort of combination therapy allows lower pressure to be used with CPAP and a more comfortable fit. The oral appliance uses a connection to hold standard Fisher Paykel mask comfortably without the use of straps. It is also possible to make a custom acrylic mask for difficult patient issues. Custom masks use the same technology that allows patients to wear dentures on much more tender oral tissues compared to the skin.

DURABLE MEDICAL EQUIPMENT SUPPLIERS MUST BE HELD RESPONSIBLE FOR MONITORING CPAP USE AND INSURING THAT PATIENTS WHO DO NOT USE CPAP REGULARLY ARE EDUCATED TO THESE NEW DANGERS. IT IS NO LONGER ACCEPTABLE TO IGNORE THE FACT THAT CPAP COMPLIANCE OVERALL IS POOR.

Dr Shapira treats patients with comfortable oral appliances in his Gurnee, Illinois general dentistry practice (http://www.delanydentalcare.com/sleep_apnea.html) and in the offices of Chicagoland Dental Sleep Medicine Associates (http://www.chicagoland.ihatecpap.com/).