Karen Loftus (Host): This is Community Connect: presented by Tampa General Hospital. I'm Karen Loftus. Joining me is Dr. Suketu Shah, a sleep medicine specialist at Tampa General Hospital's ENT Institute and USF Health's Department of Otolaryngology in the Division of Snoring and Sleep Disorders. Welcome to the podcast, Dr. Shah.

Suketu Shah, MD: Thank you, Karen.

Host: So, we're here to talk about sleep apnea, specifically obstructive sleep apnea and cardiovascular health. As we get into the conversation, Dr. Shah, it's always best to make sure our listeners get an overarching idea of the topic that we're discussing. So, can you start by explaining what exactly sleep apnea is?

Suketu Shah, MD: Sure. So, obstructive sleep apnea is kind of a repetitive closure of your airway when you're sleeping at night. And so, the airway gets obstructed because it gets blocked up, and these repeated kind of obstructions and blockages put a stress on someone's body, impact how you're able to stay in a deeper sleep. And so, it impacts the restorative functions of sleep in your body. And those different mechanisms then lead to different health effects that occur upon individuals from simple things such as tiredness to other more significant health conditions, including cardiovascular conditions, as we'll talk about today.

Host: Okay. So, you mentioned the tiredness. Many people might assume snoring, daytime fatigue are just part of getting older. Is that true? And are those actually some common signs of maybe sleep apnea?

Suketu Shah, MD: So yes, although when we get older we are probably going to be a little bit more tired than when we are younger, it just does not mean that everyone who gets older gets tired. And so, you definitely want to make sure that there's no medical condition for this. And so, you always want to differentiate, is there obstructive sleep apnea that's going on, besides any other medical problems that your primary doctors have probably evaluated for, but is there obstructive sleep apnea? Because again, if one has obstructive sleep apnea, one of the initial presenting complaints is the sensation of tiredness or fatigue or just not feeling as well-rested through the nighttime.

Host: So, how do people know the difference then? When should someone talk to their doctor if they're having some of these symptoms?

Suketu Shah, MD: So, I think the conversation should really be anytime you feel any tiredness, you should actually just bring that up to your physician, right? So when you and your physician or your nurse practitioner provider, and just talking to them in regards to tiredness. They'll usually make sure there's no other medical condition. They'll check lab work. But generally speaking, if individuals have some of the signs that might make someone more suspicious for having sleep apnea, it'll usually trigger a screening test for sleep apnea to see if somebody has that. And generally, these screening tests for sleep apnea are usually home sleep tests, so a very easy device to perform at home. And so, generally a very easy entity to perform.

Host: Okay. Now, who might be at risk for sleep apnea? And what are some of the main risk factors that people should know about?

Suketu Shah, MD: So generally, in the younger population, we always think of sleep apnea, obstructive sleep apnea being a weight-related phenomenon. So, sometimes when patients kind of look at their own body habitus, those who have a body mass index that is elevated. So, a body mass index over 30, and you can go onto any website and put in a body mass index calculator, putting in your height and your weight, and it will let you know where your body mass index is. If you have a body mass index over 30, you actually meet the criteria of obesity class I. Those individuals will have a higher risk. Even those who are overweight with a body mass index over 25 still have a risk. For men, if your neck size is 17 inches or greater, you will have a higher risk of having sleep apnea. For women, about 14 and a half inches or greater neck size will increase the risk. But thinner individuals can also have obstructive sleep apnea. If you have very large tonsils, you might have sleep apnea. If you have a markedly deviated septum and something that's blocking up your nasal passage and basically obstructing the air, you can have sleep apnea, or if your jaw sits set back. So if you look at your profile and you have a jaw that is actually set back instead of kind of set neutral or set forward, that can actually keep your tongue pushed backward and increase your risk of sleep apnea, even without being someone who's overweight. And so, those are different things to look at.

And the majority of individuals will snore with sleep apnea at the younger age. However, as individuals get older, they may frequently have sleep apnea and even significant sleep apnea without snoring. So, snoring is definitely with our younger group. But after the age of about 50, snoring may not necessarily be associated with the sleep apnea, especially after 60 or 70.

Host: Ah, okay. Now, let's get to the connection between sleep apnea and heart health. How does untreated sleep apnea affect the cardiovascular system, and what conditions can contribute to that?

Suketu Shah, MD: Okay. So, like I explained before, it's kind of this repetitive obstruction that's happening at night. So, the simplest way to kind of look at it or think about it, right? So, when the airway is closing off a little bit, it basically makes your body feel like it's being strangled.

So if your body feels it's being strangled, you get a sympathetic response or a sympathico-mimetic response to this. So in simple terms, you kind of get a microadrenaline release is probably the easy way to think about it. So, every time you're being choked, body doesn't like it, you get this kind of stress release that goes on, and these repetitive releases that are occurring through the night are going to impact your cardiovascular system. So, people will sometimes get heart rates that go up and down. They might feel palpitations at night. But this occurring also impacts some inflammation issues in your body and not getting quality of sleep. So over time, we know that there's an increased risk of cardiac arrhythmias. We know that there's increased risk of plaque formation within vessels. And so, we know that the cardiovascular risk for heart attacks goes up, for strokes goes up, and again, cardiac arrhythmias go up with sleep apnea. And this has been studied, and data has shown even if we remove obesity and remove other risk factors, it has been associated just with the sleep apnea alone, even when we control for other entities with that.

Host: And thinking about it maybe the other way around too, if somebody already has some of those health concerns, maybe like a high blood pressure, heart disease, or another health condition possibly linked to sleep apnea, can treatment still make a meaningful difference?

Suketu Shah, MD: Absolutely. So, there's a lot of folks who, you know, they've already developed these health problems. They never got the chance to either get tested or the presentation of the symptoms. They just didn't get a chance to kind of discuss that because the health issues were so significant. But even treating even after you have those health conditions is very important because it allows the medications that you're taking for this or the treatments that you're taking for those conditions to be used more effectively, because we're taking care of the stressor situation that's occurring at night. And so, that's why we want to treat that to help and reduce cardiac arrhythmia risks and cardiovascular risk of strokes and heart attacks.

Host: Yeah, that makes sense. Now, so what treatments are available? What treatment options do people have? And then, how do you determine which approach is going to be right for each patient?

Suketu Shah, MD: Yeah. So, the treatments we generally separate into kind of three generally larger categories. We talk about treatments that are what we call PAP therapy or positive airway pressure therapy, so most commonly a CPAP device. So, it's a device that basically is a facial interface or a mask connected to a little machine that generates air pressure, not oxygen. And that air pressure generally keeps your airway open at night so it doesn't collapse down. And the machines these days are extremely silent. They get rid of any snoring sound, so anyone else in the bedroom is very happy usually. And it makes it a much quieter bedroom, but it allows the patient to sleep very well.

Then, we also have dental appliances. So, dental appliances are made by specialty dentists generally, and it's something that goes in your mouth at night that you take out in the morning, kind of an upper and a lower mouth guard, and you're basically pulling your lower jaw or your mandible forward, and that prevents your tongue from sliding backwards.

And then, you have surgical options. Surgical options include cutting out tissue in the back of the throat, especially if you have very large tonsils or a very long uvula, includes tightening up those tissues in the back of the throat, includes correcting any nasal passage or nasal obstruction, and even includes implants such as what we call hypoglossal nerve stimulators, basically implants that go in and hook to a nerve that goes to your tongue, and you turn on a remote at night, and it basically keeps your tongue pushed forward, so your tongue doesn't fall back into the back of the throat. So generally, three larger categories and stuff that are there. And we kind of break down, you know, you were asking like how do we determine which makes the most sense. CPAP devices or PAP therapy work for mild, moderate, and severe sleep apnea. So for most individuals, we'll almost always start with that because it's non-invasive, easy to start, and kind of works across the spectrum, and we see how well people do. And generally speaking, about 80% of people actually do very well, as long as the pressures are correct.

The individuals who have had difficulties with CPAPs or they get put on a machine, they kind of get put on a wide range pressure, but the pressures haven't been adjusted within a month based on the patient's complaints and how the data looks on the machine. So, that's usually the main reason why people have trouble if there's not a very close follow-up with adjustments in pressure.

In individuals who don't tolerate the CPAP, like I said, the dental appliance, generally speaking, that works best for mild or early moderate disease, but it can sometimes work for severe disease if people have a very set back jaw and it pulls that jaw forward well. So, those are the things we look at for those individuals.

And then surgery, we try to reserve for the moderate to severe category is what we generally try to reserve it for. But there are some people with mild disease who just have very prominent tonsils, a uvula that's just very low hanging or a very blocked up nasal passage that we know doing that probably will make a significant improvement for them.

And sometimes people need combination therapy. Sometimes one thing alone is not a all or nothing, and we have to do combination therapy, which allows us to use kind of lower pressures or lower settings on things to make them all more comfortable for individuals.

Host: Okay. So after listing all of those out, it sounds like surgery is maybe last resort, if you will. And is it an option for everyone?

Suketu Shah, MD: So, I'm in the otolaryngology department, the ENT department. But I'm actually not an ENT surgeon. So, I was brought into this department a couple of years ago. I'm actually a medical sleep specialist. I'm actually a pulmonary critical care sleep specialist who's board-certified in all of those items. And I was brought over to specifically only do sleep medicine about two years ago within this department. And we basically look at what's the best treatment option. And like we said, about 80% of people don't necessarily need surgery. And so, I'm able to manage that, but I can help determine who is the best for surgery with that.

It's not for everyone, right? So depending on what someone's anatomy looks like, surgery is not going to make sense if the anatomy is not correct. And again, we generally try to reserve it for the moderate to severe disease group. So, we look at that. But a lot of the times I determine, you know, someone's having trouble with CPAP, but maybe their main problem is because they can't breathe well through their nose, and they don't like the big full mask.

So maybe if we can get them a little mask, it does well. So, maybe we'll just do a nasal procedure to open up the nasal passage and then still have them use CPAP, and they become more compliant. And so like I said, when we look at them and we see what their anatomy looks like, I can really make a great determination based on how they've done. And like I said, I'm not the one who's operating. So, I give them pretty open opinion as to what makes sense and stuff for them from that side.

Host: Wonderful. Thank you so much, Dr. Shah, for being a guest on our podcast and sharing your knowledge with all of our listeners.

Suketu Shah, MD: Great. Thank you so much.

Karen Loftus (Host): That has been Dr. Suketu Shah. For more information, please visit www.tgh.org/sleep. If you enjoyed this episode, please be sure to like, subscribe, and follow Community Connect: presented by TGH on your favorite podcast platform. I'm Karen Loftus, and this is Community Connect: presented by TGH. Thanks for listening.