Ictus isquémico y apnea del sueño. Relación entre trastornos respiratorios durante el sueño y estenosis carotídea / Ischemic stroke and sleep apnea. Relationship between sleep breathing disorders and carotid stenosis

Objetivo. Evaluar si existe alguna asociación entre el número de trastornos respiratorios durante el sueño (TRS) y la estenosis carotídea extracraneal (ECS) significativa en pacientes que han sufrido un ictus isquémico o ataque isquémico transitorio (AIT). Pacientes y métodos. A 68 pacientes (72,2 años; 68 % varones) supervivientes a los 2 meses de un ictus isquémico o AIT se les recogieron variables generales, antropométricas, caracteristicas y repercusión del ictus y clinica relacionada con el síndrome de apneas-hipopneas durante el sueño (SAHS). Se efectuó el estudio neurovascular mediante doppler continuo carotídeo y doppler transcraneal, realizando angiorresonancia y/o arteriografía cerebral ante sospecha de estenosis superiores al 50 %, así como una poligrafía respiratoria pasado el proceso agudo para valorar el número y tipo de TRS. Resultados. Quince pacientes (22,1 %) presentaron una ECS. El 80 % de estos pacientes tenían un índice de apneashipopneas (lAH) > 30. Los pacientes con ECS sufrían mayor somnolencia (p = 0,01), un IAH más elevado (36,2 frente a 21,9; P = 0,003) Y una mayor desaturación nocturna de oxígeno (p = 0,01). También fue significativa mente superior en este grupo la presencia de hipertensión arterial (HTA) (p = 0,003), diabetes mellitus (p = 0,01) e hipercolesterolemia (p = 0,02), aunque en el análisis de regresión logística tan sólo la presencia de HTA (odds ratio [OR]: 12,7) y de un IAH > 30 (OR: 13,6) presentaron un poder predictivo independiente de ECS. Conclusiones. La presencia de un elevado número de TRS presenta un valor predictivo de ECS independiente de la presencia de HTA. Los pacientes con ECS presentan más clínica relacionada con el SAHS previa al ictus, por lo que éste podría ser anterior al evento neurológico y funcionar como factor de riesgo para el mismo en este grupo de pacientes

Objetive. To investigate the possible relation between the number of sleep breathing disorders (SBD) and significant extracranial carotid stenosis (ECS) in patients suffering ischemic stroke or transient ischemic attack (TIA). Patients and methods. Sixty-eight patients (72.2 years; 68 OJo males) surviving two months after ischemic stroke or TIA were studied, with the collection of general and anthropometric variables, the characteristics and repercussions of stroke, and the clinical manifestations related to sleep apnea-hypopnea syndrome (SAHS). Neurovascular status was evaluated by carotid continuous doppler flowmetry and transcraneal doppler, with cerebral MR-angio and/or arteriography when suspecting stenosis > 50 %, and respiratory polygraphy after the acute phase to assess the number and type of SBD. Results. Fifteen patients (22.1 %) presented ECS. Of these, 80 % had an apnea-hypopnea index (AHI) > 30. The patients with ECS presented increased drowsiness (p = 0.01), greater AHI (36.2 vs 21.9; P = 0.003), and increased nocturnal oxygen desaturation (p = 0.01). Arterial hypertension (AHT) was also significantly more prevalent in this group of patients (p = 0.003), as was diabetes mellitus (p = 0.01) and hypercholesterolemia (p = 0.02) though logistic regression analysis only showed ART (odds ratio [OR]: 12,7) and AHI > 30 (OR: 13,6) to exhibit independent ECS predictive capacity. ConcIusions. The presence of numerous SBD is predictive of ECS, independently of the presence of ART. Patients with ECS have more SAHS related clinical mainfestations prior to stroke; as a result, SAHS could be anterior to the neurological event and act as a risk factor for the latter in this group

[Ischemic stroke and sleep apnea. Relationship between sleep breathing disorders and carotid stenosis]. / Ictus isquémico y apnea del sueño. Relación entre trastornos respiratorios durante el sueño y estenosis carotídea.

OBJECTIVE: To investigate the possible relation between the number of sleep breathing disorders (SBD) and significant extracranial carotid stenosis (ECS) in patients suffering ischemic stroke or transient ischemic attack (TIA). PATIENTS AND METHODS: Sixty-eight patients (72.2 years; 68 % males) surviving two months after ischemic stroke or TIA were studied, with the collection of general and anthropometric variables, the characteristics and repercussions of stroke, and the clinical manifestations related to sleep apnea-hypopnea syndrome (SAHS). Neurovascular status was evaluated by carotid continuous doppler flowmetry and transcraneal doppler, with cerebral MR-angio and/or arteriography when suspecting stenosis > 50 %, and respiratory polygraphy after the acute phase to assess the number and type of SBD. RESULTS: Fifteen patients (22.1 %) presented ECS. Of these, 80 % had an apnea-hypopnea index (AHI) > 30. The patients with ECS presented increased drowsiness (p = 0.01), greater AHI (36.2 vs 21.9; p = 0.003), and increased nocturnal oxygen desaturation (p = 0.01). Arterial hypertension (AHT) was also significantly more prevalent in this group of patients (p = 0.003), as was diabetes mellitus (p = 0.01) and hypercholesterolemia (p = 0.02) though logistic regression analysis only showed AHT (odds ratio [OR]: 12,7) and AHI > 30 (OR: 13,6) to exhibit independent ECS predictive capacity. CONCLUSIONS: The presence of numerous SBD is predictive of ECS, independently of the presence of AHT. Patients with ECS have more SAHS related clinical manifestations prior to stroke; as a result, SAHS could be anterior to the neurological event and act as a risk factor for the latter in this group of patients.

[Prevalence of sleep-disordered breathing in patients with acute ischemic stroke: influence of onset time of stroke]. / Prevalencia de trastornos respiratorios durante el sueño en paciente con ictus isquémico agudo. Influencia del momento de aparición del ictus.

OBJECTIVE: To analyze the prevalence of sleep-disordered breathing in patients with acute ischemic stroke and the influence of the characteristics of the stroke and time of onset. PATIENTS AND METHODS: Polysomnography was performed with an Autoset Portable Plus II in 139 patients within 72 hours of the onset of symptoms. Standard polysomnographic data, signs and symptoms related with sleep apnea-hypopnea syndrome (SAHS) prior to ischemic stroke, vascular risk factors, and characteristics and onset time (day/night) of ischemic stroke were recorded. The polysomnographic data were compared with results published for subjects of a similar age in the general population. RESULTS: The mean age was 73.6 (SD 11.1) years (59% of the patients were men). Prior to the stroke, 64.7% of the patients snored, 21.6% presented repetitive sleep apneas, and 35.6% had daytime sleepiness. The mean apnea-hypopnea index (AHI) was 29.1 (17.9) episodes/hour, the obstructive component of which was 20.1 (15.7) episodes/hour. Five patients presented Cheyne-Stokes breathing. The AHI (for all cut-points from 5 to 50), chronic snoring, and daytime sleepiness were significantly greater than those published for the general population. The stroke characteristics showed no significant differences between daytime and nighttime onset. Nighttime stroke (60.4%) was associated with a significantly higher AHI (33.3 compared to 24.7 episodes/ hour) mainly because of obstructive apneas. Nighttime stroke was also associated with a greater nighttime desaturation and a greater probability of SAHS symptoms prior to stroke (odds ratio, 2.62). In contrast, there were no differences in vascular risk factors between daytime and nighttime stroke onset. CONCLUSION: The prevalences of sleep-disordered breath- ing with clinical signs and symptoms of SAHS were high in this population of patients with acute ischemic stroke. Patients with nighttime stroke had more obstructive sleep-disordered breathing and a higher clinical probability of obstructive SAHS before stroke. These findings support the hypothesis that obstructive SAHS is a risk factor for ischemic stroke, particularly for strokes presenting at night.

[Clinical predictors of sleep apnea-hypopnea syndrome susceptible to treatment with continuous positive airway pressure]. / Valor predictivo de la clínica para la identificación de los pacientes don síndrome de apneas-hipopneas durante el sueño susceptibles de tratamiento con presión positiva continua de la vía aérea (CPAP).

OBJECTIVE: To analyze the predictive value of clinical data for identifying patients suspected of sleep apnea-hypopnea syndrome with an apnea-hypopnea index (AHI)> or = 30. MATERIAL AND METHODS: Patient characteristics, cardiorespiratory medical history, and clinical signs and symptoms were recorded for all patients. Exclusion criteria were daytime respiratory insufficiency or heart failure. All patients underwent polysomnographic testing (AutoSet Portable Plus II, ResMed Corp, Sydney, Australia) for automatic AHI calculation and manual determination of central and obstructive apneas. A logistic regression model was constructed to calculate the likelihood of an individual's presenting an AHI> or = 30 as well as the predictive value of each variable and of the final model. RESULTS: Three hundred twenty-nine patients with a mean +/- SD age of 58 +/- 13.45 years were studied; 76.4% were men. Data for 207 patients were used to construct the logistic regression model: logit (P) = 2.5 blood pressure + 1.5 Epworth test + body mass index + 0.6 repeated observed episodes of apnea 2.1. Logit(P) was loge (1-P)/P and variables were dichotomized with cut points of 11 for the Epworth test and of 30 kg/m2 for body mass index. The diagnostic sensitivity of the model was 80.2% (75%-86%), specificity was 93.4% (89%-95%), positive predictive value was 89.6% (84%-93%) and negative predictive value was 86.9% (81%-90%), such that 89.6% of the patients were correctly classified. The variable with the greatest predictive value was high blood pressure. The model was validated prospectively in the remaining 102 patients. CONCLUSIONS: Prior to diagnostic tests for SAHS, clinical data can be useful for identifying patients suspected to have a AHI> or = 30.

Valor predictivo de la clínica para la identificación de los pacientes con síndrome de apneas-hipopneas durante el sueño susceptibles de tratamiento con presión positiva continua de la vía aérea (CPAP) / Clinical predictors of sleep apnea-hypopnea syndrome susceptible to treatment with continuous positive airway pressure

OBJETIVO: Analizar el valor predictivo de las variables clínicas en la identificación de pacientes con sospecha de síndrome de apneas-hipopneas durante el sueño (SAHS) con un índice de apneas-hipopneas (IAH) superior a 30. MATERIAL Y MÉTODOS: Se recogieron datos referentes a variables generales, antropométricas, antecedentes personales cardiorrespiratorios, clínica y la sensación subjetiva del clínico. Se excluyó a los pacientes con insuficiencia respiratoria diurna o cardíaca. A todos ellos se les realizó un estudio poligráfico (AutoSet®) con determinación automática del IAH y manual del índice de apneas obstructivas y centrales. Mediante la construcción de un modelo lógistico se calculó la probabilidad individual de presentar un IAH 30 así como el valor predictivo de cada variable estudiada por separado y de la ecuación logística final. RESULTADOS: Se estudió a 329 pacientes, con una edad media ñ desviación estándar de 58 ñ 13,45 años; el 76,4 por ciento eran varones. Las variables de 207 pacientes se utilizaron para la construcción de la ecuación logística: logit P = 2,5 hipertensión arterial + 1,5 test de Epworth + índice de masa corporal + 0,6 apneas presenciadas y repetidas - 2,1; siendo logit P = loge (1-p)/p y valorando las variables como dicotómicas con puntos de corte para el test de Epworth de 11 y para el índice de masa corporal de 30 kg/m2. El valor diagnóstico de dicha ecuación fue: sensibilidad del 80,2 por ciento (7586 por ciento); especificidad del 93,4 por ciento (89-95 por ciento); valor predictivo positivo del 89,6 por ciento (84-93 por ciento) y valor predictivo negativo del 86,9 por ciento (81-90 por ciento), lo que supuso un porcentaje de pacientes correctamente clasificados del 89,6 por ciento. La variable que presentó mayor capacidad predictora fue la presencia de hipertensión arterial. La ecuación se validó prospectivamente en los restantes 102 pacientes. CONCLUSIONES: Los parámetros clínicos podrían ser útiles en la identificación, previa a la realización del estudio diagnóstico de SAHS, de aquellos pacientes con sospecha de SAHS que presentaran un IAH 30 (AU)