Sleep apnoea treatment improves symptoms post-stroke
A large study in the USA has found that starting treatment for sleep apnoea as soon as possible after a stroke or a transient ischaemic attack (TIA) significantly improves speech impairment and other neurological symptoms as well as walking and other physical functioning. Continuous Positive Airway Pressure (CPAP) therapy was shown to provide even greater benefits than tPA (tissue plasminogen activator) which is a NICE recommended drug treatment for stroke.
Although few stroke patients are currently diagnosed and treated, approximately two out of three are thought to have sleep apnoea, a disorder in which breathing during sleep is irregular. Sleep apnoea may cause low oxygen levels, high blood pressure, and heart rhythm issues. The new study followed individuals who had strokes or TIAs for up to one year after the event. Two-thirds of the 252 study participants, 41% of whom were female, were able to use CPAP effectively.
Dr Dawn Bravata, one of the study authors said, “The benefits of acute sleep apnoea management are now clear. Preliminary data suggests the sooner you treat sleep apnoea in stroke patients with CPAP, the more potent the effect of that treatment. Usually diagnosing sleep apnoea is an outpatient service, but we need to make sleep testing acutely available to stroke and TIA patients in the hospital as part of their work-up, just as we do brain imaging, lab testing and cardiac monitoring as part of the initial stroke/TIA evaluation.”
Patients in the study were from five hospitals and were randomized to a control group (usual care) without sleep apnoea treatment or to one of two intervention groups (standard or enhanced care), both of which included sleep apnoea diagnosis and treatment. The study results add to the body of evidence that supports the diagnosis and treatment of sleep apnoea early after a stroke or TIA event. In addition to the robust literature that supports the treatment of sleep apnoea in the general population, emerging data have suggested that patients with cerebrovascular disease in the early poststroke period derive neurological benefit from the treatment of sleep apnoea.
CPAP therapy for patients with ischemic stroke or TIA who have sleep apnoea was associated with statistically significant and clinically relevant improvements in neurological symptoms (measured by the National Institutes of Health Stroke scale) and functional status (modified Rankin scale, MRS). In this study 59% of the intervention group had the best neurological symptom severity score vs 38% of controls (p=0.038), absolute risk reduction was 21%. Increasing CPAP use was associated with improvements in MRS score.
Although some stroke guidelines recommend testing for sleep apnoea, past observational studies have shown that it is not being done routinely. Following the results of this trial, diagnosing and treating sleep apnoea post-stroke acutely may become a routine part of standard practice. CPAP has been used as a therapy for sleep apnoea for many years and has an excellent safety record. It can be used safely in conjunction with other stroke therapies.
Use of continuous positive airway pressure (CPAP) therapy is associated with improved neurological functioning in patients with acute stroke or transient ischaemic attack with obstructive sleep apnoea. This study suggests that patients should receive screening for sleep apnoea early in the treatment process and then receive treatment with CPAP, and these results need to be confirmed in larger trials.
Bravata D, Sico J, Fragoso CA, et al. Diagnosing and treating sleep apnea in patients with acute cerebrovascular disease. J Am Heart Assoc. 2018;7: e008841.