EAN/ERS/ESO/ESRS statement on the impact of sleep disorders on risk and outcome of stroke

Abstract

@ERSpublicationsEvidence suggests a bidirectional relationship between sleep and stroke. However, the pathophysiological base of the associations and the possibilities of improving prevention and outcome through sleep-related interventions require further evaluation.ABSTRACT Sleep disorders are highly prevalent in the general population and may be linked in a bidirectional fashion to stroke, which is one of the leading causes of morbidity and mortality.Four major scientific societies established a task force of experts in neurology, stroke, respiratory medicine, sleep medicine and methodology, to critically evaluate the evidence regarding potential links and the impact of therapy. 13 research questions were evaluated in a systematic literature search using a stepwise hierarchical approach: first, systematic reviews and meta-analyses; second, primary studies postdating the systematic reviews/meta-analyses. A total of 445 studies were evaluated and 88 included. Statements were generated regarding current evidence and clinical practice.Severe obstructive sleep apnoea (OSA) doubles the risk for incident stroke, especially in young to middle-aged patients. Continuous positive airway pressure (CPAP) may reduce stroke risk, especially in treatment-compliant patients. The prevalence of OSA is high in stroke patients and can be assessed by polygraphy. Severe OSA is a risk factor for recurrence of stroke and may be associated with stroke mortality, while CPAP may improve stroke outcome. It is not clear if insomnia increases stroke risk, while pharmacotherapy of insomnia may increase it. Periodic limb movements in sleep (PLMS), but not restless limb syndrome (RLS), may be associated with an increased risk of stroke. Preliminary data suggest a high frequency of post-stroke insomnia and RLS and their association with a less favourable stroke outcome, while treatment data are scarce.Overall, the evidence base is best for OSA relationship with stroke and supports active diagnosis and therapy. Research gaps remain especially regarding insomnia and RLS/PLMS relationships with stroke. This article has an editorial commentary: https://doi.

Sleep Disorders in Stroke: An Update on Management

“…In a systematic review of stroke and TIA patients, 10 studies all reported that BSD increased vascular events or mortality [52]. BSDs might improve with stroke recovery but elevated mortality continuously after the acute stage [53,54].…”

Cardiovascular manifestations in obstructive sleep apnea: current evidence and potential mechanisms

“…Overall, after adjusting for potential confounders (age, sex, body mass index, smoking, hypertension, and diabetes), untreated OSA conveys a 2 -fold increased risk of stroke. 70 Several prospective studies have shown an independent association of moderate -severe OSA and stroke. In the WSCS, an AHI of more than 20 events/h of sleep was associated with an increased risk of stroke over the subsequent 4 years.…”

“…78 Furthermore, a meta -analysis of available RCTs failed to demonstrate benefit of CPAP treatment on stroke risk reduction, although patients who are adherent (>4 hours per day) may still benefit and thus, a trial of treatment may still be justified. 70 The ongoing Sleep SMART (Sleep for Stroke Management and Recovery Trial) is a multisite prospective RCT whose primary outcome is to determine the effect of CPAP on reducing stroke recurrence, incidence of ACS and all -cause mortality, cardiovascular mortality in patients with central sleep apnea treated with adaptive servo-ventilation (servo -controlled inspiratory pressure support on top of expiratory positive airway pressure). Posited reasons for this negative outcome included a reduction in cardiac output with positive airway pressure in some patients, or a possible beneficial aspect to the Cheyne -Stokes respiration seen in central sleep apnea and eliminated by adaptive servo-ventilation.…”

Insomnia disorder: clinical and research challenges for the 21st century

“…A meta-analysis of 23 cohorts estimated the risk of having difficulties falling asleep, having difficulties maintaining sleep, early morning awakening and non-restorative sleep. Difficulties both falling asleep and maintaining sleep were associated with an increased risk of CVD events 29,30 On the other hand, sufficient sleep duration in addition to all four traditional healthy lifestyle factors (physical activity, nutrition, smoking and alcohol intake) was associated with 65% lower risk of CVD and 83% lower risk of fatal CVD in one large European cohort 31 However, it is still unknown whether the association of insomnia with cardio-metabolic risk is causal due to reverse causation bias and residual confounding factors inherent to observational studies.…”