Snoring and Heart Failure - Types and Management

Introduction:

Snoring is a common sleep disorder, mostly encountered in middle-aged individuals. Snoring can occur as an independent phenomenon or as a manifestation of a sleep disorder, such as OSA. Although all snorers do not have OSA, it is a cardinal symptom of OSA. It is now recognized as a clinical disorder related to increased cardiovascular disorders such as heart failure, hypertension, coronary artery disease, and, thus, morbidity. Therefore, early diagnosis and optimum treatment of snoring related to OSA are of paramount importance. however, such a situation is difficult to determine in the case of isolated snoring due to a lack of sufficient studies.

What Are the Types of Snoring?

1. Isolated snoring is often harmless.

2. Snoring due to OSA poses a moderate risk for heart disease.

What Happens in Snoring That Is Related to OSA?

The reason behind OSA is that airflow resistance is increased in certain areas of the upper respiratory tract during sleep. These areas are further compromised by a sleep-related lowering of muscle tone along with the effects of gravity due to being in the supine position. Because of that, airflow may be decreased up to 50 %, leading to hypopnea or absence in case of apnea for at least ten seconds until the muscle tone of the upper airway increases, which finally allows the resumption of normal ventilation. This regaining normal airflow is often associated with waking up or shifting to a lighter sleep stage. this cycle may repeat itself as the deeper sleep resumes, leading to muscle tone decline.

How Is Snoring Related to OSA Associated with Heart Failure?

OSA episodes expose the cardiovascular system to the following consequences;

• Intermittent hypoxia (lower blood oxygen levels).

• Oxidative stress due to chemical substances released because of lower oxygen levels in the blood may lead to long-term damage to vessels, and the tendency to develop hypertension increases.

• Lower blood oxygen levels may trigger systemic inflammation.

• Exaggerated negative intrathoracic (chest cavity) pressure because of repetitive forced inspiration against the obstructed or closed airway sympathetic overactivation.

• Hypertension is often seen in Individuals with OSA as they frequently have repetitive incidents of elevated blood pressure related to their apneic episodes. This potentially manifests a non-dipper pattern where blood pressures do not lower sufficiently at night in hypertensive individuals. In addition, in some cases with OSA, hypertension does not control, even with multiple antihypertensives.

These effects collectively can impair the contractility of the heart's musculature and cause the development and progression of heart failure.

What Is the Impact of OSA on Heart Failure?

OSA is very common in individuals with heart failure. Moreover, OSA is frequently present in individuals with heart failure. Approximately one-third of individuals with heart failure have CSA.

Obesity in men and women over 60 is a significant risk factor for OSA in people with heart failure. The major risk factors for OSA in heart failure are male sex, hypocapnia, decreased blood carbon dioxide levels, atrial fibrillation, and age over 60.

How Are Isolated Snoring and Snoring Related to OSA Diagnosed?

The diagnostic evaluation of snoring is mainly based on the history and physical examination.

A. Isolated Snoring: International Classification of Sleep Disorders provides the criteria for isolated snoring as given below;

• The affected person or their bed partner notices acoustic phenomena related to breathing, generally inspiratory during sleep.

• The affected person does not complain of any sleep disorder that may causally attribute to snoring.

• Sleep medicine diagnostics show no indication of another sleep-related breathing disorder.

B. Snoring Due to OSA:

• Traditional screening techniques for OSA are overnight polysomnography (sleep study to diagnose sleep disorders). Current recommendations are limited as screening scales' sensitivity, and specificity need to be better established.

• However, the clinician may prescribe polysomnography in case of excessive snoring or daytime sleepiness. In addition, if the person snores and the presence of other clinical features of OSA, including witnessed apnea, morning headaches, frequent awakening, cognitive deficits, and other clinical findings, such as cardiac dysrhythmia, hypertension, cardiovascular, obesity, or cerebrovascular disease the clinician may suspect OSA and advice screening test.

How Is Snoring Managed?

Management protocol for snoring includes the following;

A. Behavioral Changes:

• Weight loss.

• Changing sleeping position from lying on the back to sideways.

• Avoiding hypnotics, alcohol, and narcotics before bedtime.

• Exercise training improves sleep efficiency.

Definitive treatment includes CPAP (continuous positive airway pressure, oral appliances, and surgery to enlarge the upper airway.

B. CPAP Therapy (Common Treatment for Obstructive Sleep Apnea):

It utilizes devices specially designed to supply constant pressure flow to stent the airways open continually. The benefits of CPAP therapy include better sleep quality, reduce snoring, and lesser daytime sleepiness. It can also improve hypertension and lower blood pressure, enhance cellular function, improve insulin sensitivity, and improve insulin resistance. The presence of untreated OSA in individuals has an 82 % risk of recurrence of cardiac disorder within a year. in individuals who are treated for OSA, that risk gets half. Moreover, CPAP therapy can be used safely for all ages, including children.

C. Oral Appliances:

Oral appliances are simple, effective, and cost-efficient alternatives to treat OSA. It is an oral device inserted in the mouth to alter the upper airway to manage snoring and OSA. Oral appliances are fitted by a qualified dental surgeon who is trained and experienced in oral health, dental occlusions, temporomandibular joints, and associated oral structures. Oral appliances keep the lower jaw and tongue in a forward position while sleeping, stopping them from falling back and blocking the airway. Few appliances, such as the palatal lift appliances, prevent vibration of the soft palate by elevating it. The vibration of the soft palate is the most frequent reason for snoring.

D. Surgical Procedures:

• Uvulopalatopharyngoplasty, which comprises the removal of the tonsils, uvula, and posterior velum, is the most common surgical therapy for OSA.

• Tracheostomy.

• Hypoglossal Nerve Stimulation.

• Maxillomandibular Advancement Surgery.

• Adenotonsillectomy.

• Trans Oral Robotic Surgery.

Conclusion:

OSA is more prevalent in heart failure persons than in any other population. Study data shows that around 75 % of people with heart failure have OSA. Moreover, it has adverse effects on the heart's function and can lead to the occurrence and progression of heart failure. Individuals with moderate or severe OSA with accompanying comorbidities require treatment, including behavioral, dental, medical, and surgical procedures. Taking control of this manageable risk factor will significantly affect the prevalence of heart failure.