The Effect of Sleep Disordered Breathing on the Outcome of Stroke and Transient Ischemic Attack: A Systematic Review

Abstract

Study Objectives: The primary objective was to systematically review the literature on how sleep disordered breathing (SDB) affects recurrence and death among stroke or transient ischemic attack (TIA) patients. A secondary objective was to evaluate how treatment of SDB with continuous positive airway pressure (CPAP) affects the risk of recurrence and death in these patients. Methods: Adults (18+) with a stroke or TIA diagnosis were eligible for inclusion. Case groups consisted of patients with a sleep disorder. The outcomes of interest were all-cause mortality, recurrent vascular events, and case fatality. Results: Ten articles covering 1,203 stroke and TIA patients were included in the review. The results generally support a dose-response relationship between severity of SDB and risk of recurrent events and all-cause mortality in stroke and TIA patients. Three small-scale articles with substantial risk of bias evaluated the effects of CPAP therapy, and the results are inconclusive. Data on case fatality is too sparse to be conclusive. Conclusions: Existing studies provide suffi cient data to establish obstructive SDB as a negative predictor of all-cause mortality and recurrent vascular events following stroke or TIA. The ability of CPAP treatment to lower the risk of serious adverse outcomes after stroke remains controversial because of substantial risk of bias identifi ed in most of the eligible studies addressing this relation. Additional studies are needed. S leep disordered breathing (SDB) is a term used to describe nocturnal breathing and ventilatory problems. SDB includes obstructive sleep apnea, which is defi ned as partial or complete closure of the upper airways and central sleep apnea, which describes apneic events due to lack of respiratory effort.1 The severity of SDB is measured by the number of apneas and hypopneas per hours of sleep, the apneahypopnea index (AHI).SDB has been associated with 2-3 times higher risk of incident stroke in several large well-designed prospective studies.2-5 Moreover, a recent meta-analysis concludes that SDB with an AHI > 5 events/hour is seen in 72% and with AHI > 20 events/hour in 38% of all stroke or transient ischemic attack (TIA) patients. 6 The highest prevalence of SDB is seen among male patients, patients with recurrent strokes, and those with stroke of unknown etiology. The underlying mechanisms explaining a high prevalence of SDB among stroke and TIA patients remain to be established, but the hypothesized mechanisms behind a deleterious effect of SDB on stroke incidence and prognosis include hypertension, endothelial damage, cardiac arrhythmias, variability in cerebral blood fl ow, and oxygen desaturation . 7-9Two previous reviews have found that SDB in stroke patients leads to poorer outcomes and increased risk of recurrent strok e. 10,11 Another review is inconclusive about the benefi ts from treatment of SDB after stroke. 12 The relationship between stroke and SDB is being increasingly discussed in the scientifi c 12,13 and we aimed to systematically eval...

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