Affiliations: Honolulu, HI
Dr. Morgan is an Associate Professor at the University of Hawaii School of Medicine, and Director of the Sleep Center at the Kuakini Medical Center.
Correspondence to: Edward Morgan, MD, FCCP, Suite 405, 321 N Kuakini St, Honolulu, HI 96817; e-mail:lungs@ATTGlobal.net
Folk tales are common in Asia as to what constitutes a good night’s sleep. “Snoring at night means you have had a good night’s sleep” is one. “Drinking tea at night means you will have a good night’s sleep” is another. We now know that both of these conceptions may not be correct.
The blending of various specialities into what we now know as sleep medicine has been an interesting journey. Neurologists began to investigate sleep, and what they uncovered at night was amazing. During the “silent” hours of sleep, abnormalities in breathing would scare even the most aggressive physician.1Not long after, an article appeared in the British literature linking snoring to stroke, and questions began to arise as to the possible association.2
Soon, “everyone” began to investigate sleep. Sleep became one of the “uninvestigated horizons” that was open to all fields of medicine. Advances occurred rapidly, but a low point in such investigations was a report implying that sleep-disordered breathing was overdiagnosed and not of significant importance.
That report only fueled further investigation. Much of the investigations required large-scale epidemiologic studies such as the Sleep Heart Health Study3and other epidemiologic studies. Soon the evidence became clear that there was a probable association between sleep-disordered breathing and hypertension.4
“Now they’ll pay attention, now that the heart is involved,” was a statement made by one of the first investigators of sleep-disordered breathing. Soon, reports began to add up, showing an association between sleep-disordered breathing and left ventricular dysfunction. Nasal continuous positive airways pressure had already become one of the primary treatments of congestive heart failure due to left ventricular dysfunction.5
The article in this issue of CHEST (see page 558) adds further documentation of the association between sleep-disordered breathing and the heart, and adds one more piece of information as to the association between the silent hours of sleep and the heart. No longer can sleep-disordered breathing/sleep apnea be considered a comical and rare syndrome involving patients who are overweight and sleepy (the pickwickian syndrome). We now know that sleep-disordered breathing/sleep apnea is associated with vehicular accidents, and the evidence is mounting as to the association with the heart.
The hard thing to understand about sleep apnea is that it is “sleep” apnea. For physicians, we can understand the implications. For the lay public, however, when one mentions that sleep apnea might be associated with hypertension, the lay response is that “my BP is normal.” Often, one needs to educate patients that it is sleep apnea, and not “day” apnea. The elevations in BP during an apnea can be astounding, particular when they occur at altitude. But even at sea level, the normal cardioprotective mechanisms are thwarted in patients with hypertension who have sleep-disordered breathing.
The next chapter is in the journey of being written. This chapter is beginning to show us that abnormalities in breathing may differ in racial groups, some having mostly apneas whereas others having mostly hypopneas. The current standard of combining both apneas and hypopneas into a common number allows us to better evaluate patients in all parts of the world who might have an association between sleep-disordered breathing and the heart. “Snoring at night means you had a good night’s sleep” may no longer be a valid folk tale in the future.
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